Presented  by 
David  B.  Bosvrorth,   D.   0. 


COLLEGE   OF  OSTEOPATHIC   PHYSICIANS 
AND  SURGEONS  •  LOS  ANGELES,  CALIFORNIA 


THE 

MECHANICS  OF  SURGERY 


COMPRISING 


DETAILED  DESCRIPTIONS,  ILLUSTRATIONS  AND  LISTS  OF 

THE   INSTRUMENTS,  APPLIANCES  AND  FURNITURE 

NECESSARY  IN  MODERN  SURGICAL  ART 


BY 

4 

CHARLES  TRUAX 


CHICAGO,  U.  S.  A. 

1899 


Entered  according  to  act  of  Congress  in  the  year  1899  by 

CHARLES  TRUAX 

In  the  office  of  the  Librarian  of  Congress  at  Washington. 
ALL  RIGHTS  RESERVED. 


HAMMOND   PRESS. 
W.  B.  CONKEY  COMPANY,  CHICAGO. 


'TO  the  Medical  Profession,  from  the 
teachings  and  writings  of  which 
the  information  contained  in  this  work 
has  been  almost  exclusively  gleaned, 
this  volume  is  gratefully  inscribed. 


CONTENTS. 


CHAPTER.  PAGE. 

I.  HISTORY,  CONSTRUCTION  AND  CARE  OF  INSTRUMENTS 1 1 

II.  MECHANICAL  AIDS  IN  DIAGNOSIS 22 

III.  TRANSPORTATION  OF   PATIENTS 83 

IV.  EQUIPMENT  OF   HOSPITAL 88 

V.  OPERATING    APARTMENTS  AND  EQUIPMENT 97 

VI.  APPAREL  EQUIPMENT  OF  SURGEONS  AND  ASSISTANTS 133 

VII.  STERILIZATION 138 

VIII.  ANESTHESIA 178 

IX.  HYPODERMIC  INJECTION 190 

X.  PARACENTESIS 201 

XL  INJECTION  APPARATUS 210 

XII.  TRANSFUSION  OF  BLOOD  AND  INTRA-\TENOUS  INJECTION 212 

XIII.  ARTIFICIAL  RESPIRATION 215 

XIV.  MECHANICAL  CAUTERIZATION 218 

XV.  RESOLUTION  OF   INFLAMMATION 222 

XVI.  ELECTRO-THERAPEUTICS 235 

XVII.  MINOR  OPERATIVE  SURGERY 270 

XVIII.  BONE  AND  JOINT  SURGERY 367 

XIX.  AMPUTATIONS , 400 

XX.  GUNSHOT  WOUND  SURGERY 402 

XXI.  OPERATING  AND  POCKET  CASES 408 

XXII.  LAPAROTOMY 415 

XXIII.  GYNECOLOGICAL  SURGERY 436 

XXIV.  GENITO-URINARY    SURGERY 5?6 

XXV.  SURGERY  OF  THE  MOUTH  AND    THROAT 610 

XXVI.  SURGERY  OF  THE  ESOPHAGUS 698 

XXVII.  SURGERY  OF  THE  STOMACH ' 705 

XXVIII.  NASAL  AND  NASO-PHARYNGEAL   SURGERY 718 

XXIX.  AURAL  SURGERY 761 

XXX.  OPHTHALMIC   SURGERY 800 

XXXI.  OBSTETRIC  SURGERY 854 

XXXII.  RECTAL  SURGERY 875 

XXXIII.  PLASTIC  SURGERY 896 

XXXIV.  HERNIA 898 

XXXV.  MILITARY  SURGERY 904 

XXXVI.  FRACTURES 915 

XXXVII.  ORTHOPEDIC  SURGERY 939 

XXXVIII.  PROSTHETIC  SURGERY 999 


PREFACE 


IN  the  conception  and  preparation  of  this  work  it  is  not  assumed  to  offer 
advice  as  to  when  or  how  surgical  operations  should  be  performed.  The 
pathology,  etiology,  prognosis  and  non-mechanical  treatment  of  disease 

have  been  studiously  avoided,  save  where  necessary  to  completeness,  the 
aim  being  to  illustrate  and  describe  such  mechanical  appliances  as  research 
and  experience  have  proved  to  be  suitable,  or  best  adapted  to  the  purposes 
for  which  they  were  designed. 

It  has  seemed  fitting  that  the  preparation  of  a  book  of  this  character 
should  devolve  upon  one  who  has  enjoyed  abundant  opportunities  to  ac- 
quire a  knowledge  of  surgical  appliances  in  their  various  and  manifold 
forms  and  applications,  and  a  practical  knowledge  not  only  of  the  different 
kinds  of  surgical  instruments,  and  the  several  useful  patterns  of  each,  but 
also  of  their  construction  and  mechanical  differentiation. 

An  almost  daily  intercourse  with  physicians  and  surgeons  extending 
over  a  number  of  years,  frequent  attendance  at  clinics  in  many  parts  of  the 
world,  and  extensive  study  of  text-books  and  journals,  together  with  a 
commercial  knowledge  of  surgical  instruments  and  appliances  by  no  means 
inconsiderable,  would  seem  to  justify  the  attempt  to  fill  what  has  ap- 
peared to  be  a  hiatus  in  modern  surgical  literature. 

The  practitioner  who  desires  information  relative  to  any  particular 
surgical  instrument  or  appliance,  and  searches  in  the  standard  text-books 
for  descriptions  and  recommendations,  is  soon  lost  in  a  maze  of  unsatis- 
factory and  confusing  suggestions.  Accurate  descriptions  are  few,  differ- 
entiations of  patterns  are  almost  unknown  and  definite  reasons  for  prefer- 
ring one  model  rather  than  another  are  often  absolutely  wanting.  If  the 
practitioner,  still  in  doubt,  resorts  to  a  surgical  instrument  catalogue,  he 
finds  only  illustrations,  often  inaccurately  designed,  and  as  a  rule  poorly 
executed,  which  convey  no  information  other  than  the  name  and  price.  In 
despair  he  usually  chooses  whatever  instrument  seems  on  a  cursory  exami- 
nation to  be  the  best  adapted  to  his  purpose,  but  has  only  a  vague  idea  of 
the  merits  of  the  appliance  as  regards  the  case  in  hand. 

If  the  practitioner  corresponds  with,  or  visits  the  surgical  instrument 
dealer,  he  often  fares  no  better,  for  the  latter  is  only  too  likely  to  have  no 
knowledge  of  anatomy  or  operative  technique.  Too  frequently  he  buys 
and  sells  instruments  just  as  the  hardware  dealer  does  common  tools,  with 
but  little  more  information  regarding  their  proper  construction  and  applica- 
tion than  is  involved  in  the  name,  cost,  selling  price  and  general  mechanical 
principles.  This  being  true,  is  it  at  ail  surprising  that  a  large  percentage 
of  surgical  instruments  are  found  unsatisfactory,  and  that  designers  and 
makers  are  so  generally  condemned? 

The  instrument  maker,  on  the  other  hand,  who  happens  to  be  of  a 
mechanical  turn  of  mind  and  fairly  well  informed  in  operative  surgery,  can 
usually  give  judicious  advice  in  the  selection  of  instrument  patterns. 

How  much  benefit  the  world  in  general  and  the  science  and  art  of  surgery 
in  particular  have  derived  from  improved  methods  in  the  manufacture  of 


8  PREFACE. 

surgical  instruments  would  be  difficult  to  determine.  That  the  surgeon 
has  received  full  credit  for  such  improvements,  there  is  no  question,  and 
yet  the  artisan  has  in  all  ages  contributed  largely  to  them.  The  micro- 
scope, electric  battery,  self-registering-  thermometer,  thermo- cautery  and  a 
large  number  of  other  valuable  instruments  and  appliances  were  invented 
by  mechanics,  however  much  they  may  have  been  modified  at  the  sugges- 
tion of  the  surgeon. 

Lithotrity  was  made  possible  only  after  the  mechanic  had  successfully 
overcome  obstacles  that  stood  for  ages  in  the  way  of  success.  The  neatly  con- 
structed metallic  handles  and  aseptic  locks  and  joints  which  characterize 
modern  instruments  are  the  work  of  the  surgical  instrument  mechanic,  and 
in  the  great  achievements  that  have  marked  the  advance  of  surgery,  par- 
ticularly in  the  closing  years  of  the  ipth  century,  he  should  have  that  recog- 
nition which  entitles  him  to  at  least  a  small  percentage  of  the  glory  of 
surgical  progress. 

In  the  preparation  of  this  work,  great  care  has  been  exercised  as  to 
what  is  properly  within  its  scope.  For  example,  directions  are  given  for 
the  preparation  of  the  plaster  of  paris  bandage,  but  none  for  its  application. 
Appliances  and  methods  for  the  removal  of  plaster  of  paris  splints  and 
jackets  and  for  the  preparation  of  the  latter  for  re-application,  are  only  sug- 
gested, while  on  the  other  hand,  rules  are  given  for  the  application  of  the 
leather  jacket  in  cases  of  spinal  curvature. 

The  reason  for  this  discrimination  is  that  the  practical  clinical  applica- 
tion of  a  plaster  splint,  or  jacket,  belongs  to  the  surgeon  alone  and  is  de- 
scribed in  nearly  all  surgical  text-books,  while  methods  for  the  application 
of  leather  jackets  are  seldom  outlined,  this  duty  being  usually  left  to  the 
instrument  maker.  These  rules  are  therefore  included  for  the  benefit  of 
the  surgeons  in  whose  interests  this  book  has  been  written. 

One  object  sought  in  this  work  is  to  assist  in  securing  a  standard  nomen- 
clature for  surgical  instruments.  The  custom  of  calling  the  same  instru- 
ment by  various  names  is  annoying  and  confusing.  For  instance,  a  perios- 
teal  elevator  is  often  referred  to  or  described  as  a  levator,  raspatory, 
elevator,  dry  dissector  or  periosteotome ;  a  plain  spring  dressing  forceps, 
may  be  called  a  thumb  forceps,  a  dissecting  forceps,  a  plain  artery  forceps,  a 
tissue  forceps  etc. ,  and  even  standard  text-books  sometimes  refer  to  forceps 
for  hemostatic  purposes  as  "nippers.  " 

Where  an  instrument  is  known  by  more  than  one  name,  that  one  has 
been  selected  which,  from  a  mechanical  stand-point,  seems  most  nearly 
correct  or  most  commonly  used. 

Again,  the  line  of  demarkation  between  forceps,  scissors  and  punches  is 
difficult  to  trace.  Emmet's  "button-hole  scissors"  do  not  differ  in  me- 
chanical construction  from  Boecker's  "excising  forceps"  or  from  some  forms 
of  nasal  punches.  Many  varieties  of  curettes  are  called  knives,  aneurysm 
ligature  carriers  are  called  needles,  and  so  on  throughout  the  list  of  surgical 
instruments  and  appliances. 

There  seems  to  be  no  good  reason  why  instruments  of  ordinary  forms 
should  bear  names  different  from  those  by  which  they  are  known  by  me- 
chanics generally. 

No  attempt  has  been  made  to  compile  an  armamentarium  that  should 
include  all  the  instruments  in  use,  for  that  would  be  an  almost  hopeless 
task;  but  in  this  book  an  attempt  has  been  made  to  select  from  the  vast 
number  such  as  are  either  in  general  use  and  accepted  as  standard  patterns, 
or  those  which  are  recommended  by  good  authorities. 


PREFACE.  9 

In  descriptions  of  instruments  when  necessary  to  refer  to  the  "near"  or 
"far"  ends  of  each,  we  will  employ  the  terms  "proximal"  and  "distal," 
construing  these  with  reference  to  the  operator  instead  of  the  patient. 
While  this  may  be  at  times  misleading,  it  can  scarcely  increase  the  present 
confused  condition.  We  are  well  aware  that  many  authors  in  speaking  of 
a  catheter  or  similar  instrument  refer  to  the  proximal  end  as  that  within  or 
to  be  passed  within  the  bladder,  and  the  distal,  as  that  external  to  the 
patient. 

A  surgical  instrument  is  no  more  nor  less  than  a  mechanical  appliance 
with  which  to  improve  manual  or  digital  manipulation.  The  distal  ends  of 
the  fingers  may  be  well  designated  as  those  farthest  from  the  hand.  There- 
fore, in  applying  these  terms  to  surgical  instruments  we  can  assume  no 
other  position  than  to  apply  the  same  nomenclature. 

As  a  matter  of  convenience  and  accuracy  in  descriptions  of  forceps  and 
scissors-like  instruments,  we  will  divide  them  into  three  parts;  viz.,  handle, 
lock  and  blade.  That  portion  of  the  instrument  on  the  proximal  side  of  the 
joint  or  lock,  and  by  which  it  is  manipulated,  will  be  called  the  handle;  the 
fulcrum  or  hinged  portion  may  be  designated  as  the  lock  or  joint;  while 
that  part  of  the  instrument  distal  to  the  lock  may  consist  of  plain  blades 
like  scissors  or  blades  that  terminate  in  a  contact  portion  that  may  be  called 
the  jaw.  The  portion  of  the  instrument  between  the  jaw  and  the  lock  we 
will  call  the  shank.  In  some  forms  of  cutting  forceps  where  the  jaws  are 
of  knife-like  construction,  they  may  be  referred  to  as  cutting  edges  or 
blades. 

In  the  arrangement  selected,  after  briefly  presenting  the  History,  Con- 
struction and  Care  of  Instruments,  the  Mechanical  Aids  Employed  in 
Diagnosis  are  considered.  This  is  followed  by  chapters  devoted  to  the 
Transportation  of  Patients  and  General  Hospital  Equipment,  including 
Sterilization  and  Anesthesia,  all  of  which  relate  to  the  necessary  prepara- 
tions for  an  operation.  The  chapters  which  immediately  follow  are  intended 
to  cover  the  fields  of  Minor  and  Major  Operative  Surgery.  In  the  latter 
all  the  instruments,  appliances  and  dressings  necessary  in  general  oper- 
ations are  fully  tabulated  and  described.  From  this  section  regional  and 
special  surgery  have  been  purposely  omitted,  the  consideration  of  their 
subjects  being  left  to  chapters  wherein  each  branch  is  fully  described  by 
itself.  An  attempt  has  here  been  made  to  formulate  two  lists,  which  shall 
include  everything  necessary  in  a  general  operation,  as,  for  instance,  the 
removal  of  a  tumor  from  the  fleshy  part  of  the  thigh  where  no  bone  is  in- 
volved. The  first  of  these  lists  is  intended  as  a  guide  for  operations  in 
the  hospital,  the  second  for  operations  at  residences.  In  these  lists  it  is 
aimed  to  incorporate  everything  from  the  operating  room  furniture  to  the 
necessary  medicines  and  the  safety  pin  with  which  the  last  bandage  is 
secured.  The  chapters  which  follow  are  devoted  to  special  and  regional 
surgery,  and  these  are  intended  to  cover  the  entire  field,  so  far  as  the  use 
of  instruments  and  appliances  is  concerned. 

In  justice  to  the  author,  the  critic  should  not  lose  sight  of  the  fact  that 
the  arrangement  and  classification  of  this  work  are  based  entirely  upon  the 
list  of  surgical  instruments  employed  in  the  conduct  of  any  given  oper- 
ation. Many  surgical  procedures  which  require  no  special  instruments  other 
than  those  described  under  the  head  of  Minor  Operative  Surgery  are  en- 
tirely omitted. 

Many  generations  have  passed  since  a  work  in  any  way  resembling  this 
has  been  published.  This  is  worthy  of  note,  for  it  would  seem  that  a  book 


10  PREFACE. 

of  this  character,  written  by  one  competent  to  compile  and  arrange  it, 
should  find  a  place  in  the  library  of  every  practitioner  of  medicine  or 
surgery. 

If  this  volume  fails  to  fulfill  the  expectations  of  its  author,  it  may  perhaps 
serve  as  a  stimulus  to  some  abler  mind  to  prepare  a  work  which  will  better 
meet  all  requirements. 

CHARLES  TRUAX. 
42,  44  AND  46  WABASH  AVENUE, 
CHICAGO. 


CHAPTER  I. 


HISTORY,  CONSTRUCTION  AND  CARE  OF 
SURGICAL    INSTRUMENTS. 


HISTORY. 

The  history  of  surgical  instruments  is  contemporaneous  with  that  of 
surgery.  Operations  were  only  possible  after  the  construction  of  the  nec- 
essary appliances.  The  catheter  preceded  catheterism,  just  as  the  crude 
lithotrites  used  by  Ammonius  and  Civiale  preceded  lithotrity. 

The  limited  number  of  instruments  required  by  practitioners  in  the 
early  ages  did  not  create  a  demand  large  enough  to  necessitate  the  erection 
of  surgical  instrument  factories  or  the  equipment  of  general  supply  houses. 
The  surgeon  in  want  of  an  instrument  was  obliged  to  secure  the  services 
of  an  artisan,  make  known  his  wants,  explain  the  mechanism  of  the  needed 
appliance  and  superintend  its  manufacture.  Instruments  under  such  cir- 
cumstances were  not  only  crude  and  expensive,  but  much  of  the  time  of  the 
surgeon  was  occupied  in  looking  after  the  many  details  necessary  to  their 
careful  construction.  It  is  not  strange,  therefore,  that  surgeons  in  those 
times  employed  few  instruments;  that  they  accomplished  such  splendid 
results  under  the  circumstances  is  more  largely  to  their  credit.  What  they 
might  have  done  with  the  modern  supply  house  from  which  to  select  means, 
can  only  be  conjectured. 

Edged  instruments  in  great  variety  were  in  use  in  the  far  East,  cer- 
tainly 700  to  1,000  years  B.  C.  They  embraced  besides  knives,  instruments 
for  scarifying,  paracentesis,  stitching,  etc.  Blunt  instruments  were  also 
employed,  particularly  forceps,  many  patterns  of  which  differ  little  in 
general  form  from  those  in  use  to-day. 

Hippocrates  trepanned  the  skull  with  a  circular  trephine  about  400 
years  B.  C.,  and  while  we  know  nothing  of  the  details  of  construction  of 
the  instrument,  it  was  probably  as  effective  as  those  employed  to-day. 
Many  forms  of  instruments  generally  considered  modern  were  in  use  in 
the  early  years  of  civilization. 

The  adaptation  of  artificial  limbs  dates  back  to  the  ages  of  Egyptian 
mythology.  Obstetrical  forceps  were  employed  long  before  the  dawn  of 
the  Christian  era,  while  catheters  would  seem  to  have  been  in  use  as  far 
back  as  the  annals  of  history.  Even  the  lithotrite,  generally  accredited  to 
Civiale,  was  employed  by  Ammonius,  a  student  of  Erasistratus,  about  250 
years  B.  C. 

The  mines  of  Pompey  disclose  a  variety  of  surgical  instruments,  some 
of  which  are  almost  perfect  models  of  modern  patterns.  Male' and  female 
catheters,  trocars,  scissors,  forceps,  tenacula,  syringe  pipes,  etc.,  bear 
ample  evidence  that  the  construction  of  surgical  instruments  is  not  alto- 
gether modern.  Bivalve  and  trivalve  speculums,  the  latter  arranged  so 

11 


12  HISTORY. 

that  retraction  of  one  blade  by  screw  power  caused  equi-expansion  of  all 
three,  are  not  exceeded  in  clever  mechanism  by  more  recent  designs. 

Tracheotomy  tubes  and  instruments  for  embryotomy  were  in  use  by 
Paulus  Aegineta  as  early  as  the  seventh  century.  In  fact,  it  would  seem 
that  nearly  all  our  more  common  instruments  and  appliances,  and  many 
of  our  so-called  new  inventions  are  either  fac-similes  or  modifications  of 
instruments  devised  ages  ago. 

In  the  earlier  history  of  surgery,  the  operator  desiring  an  instrument  was 
obliged  to  select  an  artisan  skilled  in  working  the  particular  material  to  be 
employed  in  its  construction.  Steel  workers,  copper  and  silversmiths,  needle 
grinders,  turners  of  wood,  bone  and  ivory,  sewers  of  leather,  glass  blowers, 
silk  and  hemp  spinners,  in  fact,  almost  the  whole  range  of  industries  was 
invaded  that  the  surgeon  might  properly  equip  himself  for  practice. 

Gradually  the  cutler  who  made  and  sold  knives  and  who  usually  kept 
a  shop,  absorbed  a  good  percentage  of  this  trade  by  keeping  on  hand  a 
small  assortment  of  surgical  instruments,  and  engaging  workmen  who 
became  more  or  less  skilled  in  the  manufacture  of  medical  appliances. 
These  small  manufacturers  changed  their  signs  from  "Cutler  and  Scissor 
Grinder"  to  "Cutler  and  Surgical  Instrument  Maker,"  and  from  these  in 
more  modern  times  have  developed  the  surgical  instrument  maker  and 
the  physician's  supply  house,  where  almost  anything  pertaining  to  the 
mechanical  treatment  of  disease  may  be  obtained. 

The  nineteenth  century  has  not  only  marked  an  era  in  the  science  and 
art  of  surgery  but  in  the  manufacture  of  the  necessary  appliances  as  well. 
The  subdivision  of  the  practice  of  general  surgery  into  specialties  and  the 
multiplicity  of  operations  consequent  thereon  have  increased  the  demand 
for  instruments  to  an  unprecedented  degree. 

The  dawn  of  aseptic  and  antiseptic  surgery  contributed  much  toward 
the  development  of  surgical  instruments,  because  it  not  only  necessitated 
greater  care  in  the  construction  of  instruments,  but  also  made  possible 
many  operations  not  before  attempted. 

Manufacturers,  who  a  few  years  ago  measured  their  annual  trade  by 
hundreds,  now  count  it  by  thousands  and  hundreds  of  thousands  of  dollars. 
The  small  shop,  in  the  rear  portion  of  which  the  proprietor,  perhaps  with 
one  or  two  assistants,  made  his  wares,  has  given  place  to  large  and  thor- 
oughly equipped  factories,  where  anything  from  a  sewing  needle  or  a 
sphygmograph  to  an  air-compressing  outfit,  an  office  electric  battery  or  the 
furniture  necessary  for  a  hospital  operating-room  can  be  constructed  on 
short  notice.  Such  instruments  as  knives,  needles,  and  other  forgings, 
which  require  hand  labor  exclusively  for  their  production,  can  be  manu- 
factured by  workmen  who  devote  their  entire  time  to  the  making  of  one 
class  of  instruments,  and  thereby  attain  great  proficiency  in  their  con- 
struction. 

The  crude  and  often  unwieldy  instruments  that  characterized  the  prac- 
tice of  surgery  in  former  generations  have  given  way  to  smaller  and  more 
delicate  appliances.  Experience  has  demonstrated  that  the  proper  appli- 
cation of  a  delicate  though  finely  constructed  instrument  is  of  far  greater 
utility  than  the  use  of  greater  force  by  heavier  instruments. 

The  surgeon  of  to-day  is  not  only  able  to  secure  special  instruments  for 
almost  every  known  operation,  but  to  make  a  selection  from  various  pat- 
terns designed  for  that  purpose.  Competent  workmen  can  also  be  found 
in  almost  every  city  who  are  prepared  to  execute  the  ideas  of  the  surgeon 
when  instruments  of  special  design  are  required. 


HISTORY.  13 

The  manufacture  of  instruments  has  maintained  an  even  pace  with  the 
advance  in  the  art  of  surgery,  and  the  instrument  maker  of  the  present 
day  may  justly  feel  proud  of  his  achievements,  as  is  evidenced  by  the 
serviceable  and  perfectly  constructed  armamentaria  which  are  found  in 
the  modern  physician's  supply  house. 


14  CONSTRUCTION  OF  SURGICAL  INSTRUMENTS. 


CONSTRUCTION  OF  SURGICAL  INSTRUMENTS. 

The  value  of  a  surgical  instrument  depends  upon  the  quality  of  the 
material  employed,  the  skill  exhibited  in  its  construction,  and  the  appli- 
cation of  the  article  when  completed.  Poor  material  in  the  hands  of  skilled 
workmen,  first-class  material  in  the  hands  of  unskilled  labor,  or  good  mate- 
rial and  skilled  labor  engaged  in  manufacturing  an  inefficient  pattern, 
generally  result  in  the  production  of  worthless  appliances. 

The  construction  of  surgical  instruments,  unlike  that  of  most  other 
classes  of  goods,  requires  and  demands  the  exercise  of  a  thorough  knowl- 
edge, not  only  of  the  mechanical  features  presented  by  the  instrument,  but 
also  of  the  uses  to  which  it  is  to  be  applied.  The  educational  equipment 
required  in  the  manufacture  and  sale  of  this  class  of  merchandise  is  of  a 
standard  almost  as  high  as  that  necessary  for  the  practict  f  surgery,  be- 
cause it  is  only  by  possessing  a  practical  knowledge  of  the  uses  and  re- 
quirements of  each  instrument,  that  the  maker  and  dealer  can  furnish 
apparatus  from  which  satisfactory  results  can  be  obtained. 

As  the  cost  of  material  generally  forms  only  a  small  percentage  of  the 
value  of  a  finished  instrument,  as  the  product  of  skilled  labor  commands  a 
fair  price,  and  as  it  usually  costs  no  more  to  produce  an  instrument  from  a 
correct  than  from  an  imperfect  model,  there  is  little  excuse  for  the  creation 
and  existence  of  second-class  surgical  apparatus.  It  is  not  only  necessary 
that  the  forging,  turning,  spinning,  soldering  and  general  working  of  the 
metal  or  other  material  be  performed  by  the  highest  grade  of  skilled  labor, 
but  that  the  polishing  and  finishing  result  in  a  surface  that  will  not  pro- 
vide lodgment  for  bacteria  and  that  to  the  unassisted  eye  presents  a  per- 
fect appearance. 

In  this  respect  surgical  instruments  differ  from  ordinary  hardware  and 
approach  the  same  high  standard  of  external  excellence  that  is  so  notice- 
able in  jewelry.  In  many  cases  the  surgeon  is  obliged  to  pay  almost  as 
much  for  the  high  finish  and  superior  appearance  of  an  instrument,  as  for 
its  construction  proper. 

It  is  frequently  claimed  that  since  the  introduction  of  machinery  in  the 
manufacture  of  general  merchandise,  the  prices  of  surgical  instruments 
should,  in  justice  to  the  consumer,  be  materially  reduced.  As  evidence  of 
this,  surgeons  frequently  point  to  the  prices  at  which  similar  articles  in 
hardware  stores  are  offered  for  sale.  If  it  were  true  that  a  general  line  of 
surgical  instruments  of  acceptable  quality  could  be  manufactured  by  machine 
methods,  there  would  no  doubt  be  a  corresponding  reduction  in  prices,  but 
as  a  matter  of  fact,  there  are  few  such  articles  that  can  be  constructed  of 
proper  quality  and  finish  either  wholly  or  in  part  by  the  aid  of  more  than 
ordinary  machinery. 

In  the  first  place,  instruments  are  not,  as  a  rule,  manufactured  in  suffi- 
cient quantities  to  warrant  the  construction  of  dies,  stamps  and  other  imple- 
ments necessary  for  the  proper  drop  forging,  stamping,  shaping  and  forming 
of  metal  goods  of  this  character.  Even  if  the  demand  would  permit  of  the 
use  of  such  a  process,  the  quality  of  the  instruments  produced  by  such 
methods  would  be  in  many  cases  far  inferior  to  that  of  hand-made  goods. 
Furthermore,  the  finish  of  surgical  appliances,  whether  made  by  hand  or 
machine,  forms  a  large  percentage  of  their  cost,  and  surgeons,  as  a  rule, 
avoid  purchasing  from  those  manufacturers  whose  wares  do  not  bear  evi- 
dence of  having  been  constructed  with  the  utmost  care  and  precision. 


CONSTRUCTION  OF  SURGICAL    INSTRUMENTS.  15 

While  the  selling  prices  of  surgical  instruments  are  being  greatly  re- 
duced from  year  to  year,  it  is  not  probable  that  they  will  ever  be  satisfac- 
torily produced  at  as  low  a  cost  as  that  of  similar  articles  in  other  lines  of 
trade. 

So  far  as  possible  all  instruments  should  be  constructed  entirely  of  non- 
permeable  material,  which  can  be  readily  sterilized.  Metal  in  some  form 
is  of  course  the  chief  substance  from  which  they  are  made. 

The  material  employed  in  the  manufacture  of  surgical  instruments  de- 
pends on  the  character  of  the  apparatus  and  the  use  to  which  it  is  applied. 
Cutting  instruments  are  usually  made  from  the  finest  of  English  crucible 
steel,  because  this  special  manufacture  supplies  instruments  of  high  quality 
and  finish.  Blunt  instruments,  forceps,  braces,  and  untempered  steel  work 
are  commonly  manufactured  from  the  softer  qualities  of  steel,  such  as  the 
"Bessemer"  and  "open  hearth." 

Malleable  iron  castings  are  employed  only  to  a  limited  extent,  as,  for  in- 
stance, in  parts  of  hospital  furniture,  the  heavier  pieces  in  stands,  band- 
age rollers,  etc. 

Brass  is  second  in  importance  to  steel  as  a  material  for  use  in  the  con- 
struction of  the  implements  of  surgery.  Specula,  many  forms  of  re- 
tractors, catheters,  cases,  blunt  instruments,  and  small  castings  are  gen- 
erally made  from  this  metal.  It  can  not  only  be  worked  more  cheaply  than 
steel  or  iron,  but  it  also  takes  a  high  polish,  and  does  not  rust  under  the 
action  of  moisture  as  does  steel. 

Copper  is  employed  in  making  uterine  sounds,  probes,  applicators,  and 
in  the  construction  of  compressed-air  cylinders,  sterilizers,  etc. 

Silver,  pure,  sterling,  and  coin,  enters  into  the  construction  of  or  forms 
many  varieties  of  instruments,  the  pure  metal  being  used  in  the  manufac- 
ture of  some  patterns  of  probes  and  catheters  in  which  flexibility  is  a 
prime  consideration.  Sterling  silver  of  moderate  firmness  is,  however, 
generally  used  for  such  instruments,  while  coin  silver  is  selected  for  caustic 
holders,  eye  syringes  and  other  instruments  where  rigidity  is  essential. 

German  silver,  largely  employed  in  Europe,  is  but  little  used  in  this 
country.  From  it  are  made  a  number  of  catheters  and  canulated  instru- 
ments, some  forms  of  spring  forceps,  and  a  variety  of  cases  for  the  pocket. 

Gold,  owing  to  its  cost,  is  but  little  employed,  except  as  tubes  for  eye 
syringes,  styles,  etc. 

Platinum,  as  it  is  not  acted  upon  by  acids  and  withstands  a  high  degree 
of  heat,  has  been  found  of  superior  service  in  the  manufacture  of  caustic 
holders  and  applicators,  intra-uterine  electrodes,  electrolytic  needles,  the 
points  of  cautery  electrodes,  thermo-cauteries,  etc. 

Aluminum  is  not  suitable  for  use  in  the  construction  of  surgical  instru- 
ments, excepting  for  an  occasional  probe  or  applicator,  or  as  a  lining  for 
a  chest  or  medicine  box.  Being  soft,  its  surface  soon  becomes  indented 
and  roughened,  making  sterilization  difficult.  As  it  yields  readily  to  the 
attacks  of  some  acids,  it  easily  corrodes,  and  as  it  is  quickly  affected  by 
contact  with  corrosive  sublimate,  its  use  precludes  the  employment  of  this, 
our  most  valuable  chemical  germicide. 

Of  the  non-metallic  substances,  rubber,  hard  or  soft,  is  the  most  useful ; 
wood,  bone,  ivory  and  tortoise  shell  being  seldom  employed.  Glass  is 
necessary  in  the  manufacture  of  mirrors,  bottles,  jars  and  some  forms  of 
tubes. 

Brass,  copper,  German  silver,  rubber,  and  various  light  substances  are 
easily  worked,  and  the  cost  of  instruments  from  these  materials  and  the 


16  CONSTRUCTION    OF  SURGICAL  INSTRUMENTS. 

selling  prices  of  the  finished  products  are  comparatively  low.  When  the 
operator  is  called  upon  to  pay  the  prices  demanded  for  hand-forged  steel 
articles,  he  sometimes  feels  that  an  unfair  advantage  is  being  exercised, 
and  that  exorbitant  rates  are  being  charged  for  this  class  of  goods.  Let 
the  surgeon  so  impressed  enter  an  instrument  factory  and  there  witness 
the  forging,  filing,  shaping,  fitting,  sharpening,  polishing  and  plating  of 
ordinary  surgical  scissors  or  forceps;  let  him  watch  the  process  from 
the  time  the  workman  selects  the  bar  of  steel  from  which  to  manufacture 
the  instrument,  until  it  is  buffed  and  the  parts  put  together  ready  to  leave 
the  finishing  room,  and  it  is  reasonable  to  assume  that  he  will  thereafter 
pay  the  price  demanded  by  reputable  dealers  for  such  appliances,  and  rest 
content  in  the  knowledge  that  he  is  obtaining  value  received  for  his  in- 
vestment. 

Since  the  introduction  of  nickel  plating,  the  proper  finish  of  an  instru- 
ment is  almost  as  essential  as  any  process  in  its  manufacture.  In  former 
years  the  construction  of  surgical  instruments  was  completed  with  what  was 
known  as  a  "crocus  polish,"  followed  by  "bluing."  This  was  a  fine  finish 
without  plating.  That  such  instruments  rapidly  deteriorated  under  the 
action  of  corrosives  is  well  known,  and  it  was  only  after  the  discovery  of 
the  valuable  properties  of  nickel  that  surgical  instruments  could  be  prop- 
erly protected  from  rapid  destruction. 

While  silver  plating  is  often  desirable,  it  is  not  generally  applicable  to 
surgical  instruments.  As  rubber,  either  hard  or  soft,  when  brought  into 
contact  with  silver,  whether  solid  or  in  the  form  of  plating,  causes  a  dis- 
coloration and  oxidation  of  the  silver  surface,  it  follows  that  the  almost 
universal  use  of  rubber  has  necessitated  the  abandonment  of  silver  for 
plating  purposes  with  the  exception  of  a  few  cases,  where  its  employment 
is  still  a  necessity. 

While  a  heavy  coat  of  good- wearing  qualities  may  be  formed  of  nickel, 
it  is  so  brittle  that  if  a  nickel-plated  instrument  be  curved  the  plating  is 
likely  to  peel  off  in  scales  or  its  surface  to  chip  and  present  a  roughened 
appearance. 

Silver,  on  the  other  hand,  is  quite  flexible.  Uterine  sounds,  metal 
catheters,  probes  and  instruments  of  this  class  may  be  curved  without  in- 
juring to  any  great  extent  the  silver  plating  with  which  they  may  be  covered. 

The  process  of  nickel  plating  requires  considerable  labor  and  no  small 
degree  of  skill.  In  order  to  produce  satisfactory  results,  the  surface  of  the 
instrument  to  be  plated  must  be  smooth  and  free  from  grease  and  all  for- 
eign substances.  This  necessitates  extensive  scouring  with  acids,  alkalies, 
etc.,  that  a  thoroughly  clean  and  neutral  surface  may  be  presented  to  the 
coating  substance. 

Nickel  does  not  adhere  firmly  to  the  surface  of  steel,  but  it  possesses  a 
strong  affinity  for  copper  with  which  it  unites,  forming  a  solid  and  adher- 
ent covering.  To  obtain  perfect  results  in  nickel  plating,  therefore,  it  is 
first  necessary  that  steel  instruments  be  copper  plated.  This  may  be  se- 
cured by  placing  them  in  an  electric  bath  charged  with  copper  electrodes. 
From  this  they  may  be  transferred  to  the  finishing  bath,  where  by  electric 
action  anodes  of  nickel  may  be  caused  to  deposit  a  coating  upon  the  copper- 
plated  instrument,  the  thickness  of  the  coating  depending  on  the  strength 
of  the  current,  the  amount  of  surface  and  the  length  of  time  exposed. 

Failure  to  copper  plate  steel  instruments  or  to  thoroughly  cleanse  them 
before  plating,  will  result  in  an  imperfect  coating,  because  the  plating  in 
such  cases  is  liable  at  any  time  to  break  or  scale  off. 


CONSTRUCTION    OF  SURGICAL  INSTRUMENTS.  17 

In  the  manufacture  of  cutting  instruments,  and  particularly  of  knives, 
great  care  is  necessary.  In  order  that  the  blade  may  "take  on"  the  neces- 
sary edge,  it  requires  a  certain  degree  of  hardness  called  temper.  If  the 
blade  be  over-heated  in  the  hardening  process,  it  will  be  too  brittle  even 
when  tempered,  the  edge  "cribbing"  or  breaking  away.  Again  the  tem- 
pering may  not  be  properly  conducted,  or,  as  sometimes  happens,  the  blade 
edge  may  be  overheated  in  grinding,  in  either  case  producing  a  worthless 
instrument.  If  the  blade  is  not  heated  sufficiently  in  tempering,  or  if  the 
process  is  imperfectly  carried  out,  the  blade  will  be  too  soft  and  the  edge 
will  "turn,"  a  condition  sometimes  observed. 

In  former  years  the  handles  of  most  instruments  were  constructed  of 
wood,  ivory,  rubber  or  similar  material.  To-day,  metal  alone  is  employed 
for  this  purpose,  because  it  has  been  found  that  only  such  handles  will  per- 
mit of  continued  and  perfect  sterilization.  Of  the  metals  used,  German 
silver,  brass  and  steel  are  to  be  preferred. 

While  a  certain  number  of  depressions  and  projections,  usually  in  the 
form  of  corrugations,  are  necessary  to  enable  the  operator  to  obtain  a  firm 
grip  upon  the  handle  of  an  instrument,  this  roiighness  should  be  of  such  a 
nature  that  it  may  be  easily  sterilized  by  mechanical  measures.  Crevices, 
notches,  carvings  and  ornamentation  should  be  avoided,  and  the  manufact- 
urer should  seek  in  all  instances  to  produce  the  plainest  possible  pattern 
that  will  admit  of  a  firm  and  satisfactory  grip. 

Spiral  springs,  screws,  threads  and  complicated  mechanism  ought  to  be 
avoided  and  the  surgeon  should,  as  far  as  possible,  select  instruments  with 
plain,  rather  than  with  automatic  movements. 

The  surgeon  who  educates  himself  to  execute  difficult  and  complex 
procedures  with  simple  instruments,  will  find  that  he  possesses  great  ad- 
vantages over  those  who  use  complicated  appliances  in  their  work.  The 
manipulation  of  surgical  instruments  by  the  operator  is  like  the  deft  appli- 
cation of  a  brush  by  the  artist;  the  delicate  touch  of  a  piano  by  the 
musician ;  the  dextrous  use  of  a  tool  by  the  engraver,  or  the  skilful  em- 
ployment of  any  agency  by  the  artist  or  mechanic  in  any  profession  or 
trade. 

The  general  adoption  of  strict  prophylactic  measures  at  first  created  a 
demand  for  surgical  instruments  with  separable  parts.  The  old-fashioned 
screw  joints  were  superseded  by  the  French,  German,  Kelly  and  other  forms 
of  locks  by  means  of  which  the  blades,  springs  and  other  parts  of  instru- 
ments could  be  readily  separated  without  the  aid  of  tools.  It  was  claimed 
that  scissors,  forceps,  and  similar  instruments  when  constructed  with  screw 
locks  or  joints  were  not  easily  sterilized,  and  that  their  use,  wherever  pos- 
sible, should  be  avoided. 

As  recent  investigations  have  demonstrated  that  nearly  all  forms  of 
metallic  instruments,  including  those  constructed  with  screw  locks  and  old- 
fashioned  male  and  female  joints,  may  be  perfectly  sterilized  by  boiling, 
many  operators  are  again  demanding  instruments,  particularly  scissors  and 
artery  forceps,  with  screw  joints.  The  separable  patterns  become  more  or 
less  loose  after  the  blades  are  worn,  and  as  it  is  difficult  to  remedy  the 
defect,  the  instrument  soon  becomes  worthless.  Such  instruments,  more- 
over, after  being  taken  apart  for  cleansing,  are  frequently  mismatched 
when  assembled  for  use,  thus  forming  imperfect  ones,  while  some  forms  of 
locks  become  separated  in  service  or  if  accidentally  dropped  or  moment- 
arily laid  aside. 

These  conditions  have  induced  many  surgeons  to  return  to  the  use  of 

2 


18  CONSTRUCTION  OF  SURGICAL  INSTRUMENTS. 

instruments  with  screw  joints,  particularly  those  that  are  in  frequent  use 
during  operations. 

The  French  lock,  the  first  of  the  separable  patterns  adopted,  was  far 
from  being  perfect,  for  unless  the  operator  was  particularly  careful  in  ad- 
justing the  female  blade,  the  oval,  button-shaped  head  of  the  pin  in  the 
male  blade  would  catch  in  the  eye  of  its  mate,  in  which  case  a  slight  force 
would  turn  it  in  its  socket  and  render  the  instrument  worthless  until  re- 
paired. 

It  is  well  to  remember  that  when  adjusting  such  separable  blades  no 
force  should  be  employed  to  turn  them  in  a  position  for  use.  If  the  two 
parts  are  mates  and  the  female  blade  is  pressed  closely  against  the  opposite 
piece,  no  force  will  be  necessary  to  turn  it  if  the  instrument  be  properly 
constructed.  If  it  does  not  move  easily,  it  should  be  carefully  examined, 
and  the  fault  discovered  and  corrected  before  the  instrument  is  damaged. 

This  objection  has  been  overcome  by  new  forms  of  joints  or  locks  that 
are  not  only  separable  but  are  as  strong  as  the  ordinary  patterns.  They 
may  be  quickly  unjointed  and  as  readily  put  together  and  combine  all  the 
features  requisite  to  a  lock  of  this  kind. 

While  there  are  various  patterns  of  separable  joints,  several  of  which 
are  patented,  they  differ  little  in  mechanism,  and  all,  we  believe,  answer 
the  requirements. 

When  springs  are  employed  to  separate  or  close  the  blades  of  instru- 
ments, they  may  be  secured  by  detachable  joints.  When  the  parts  of  an 
instrument  are  separable,  each  set  of  pieces  forming  that  instrument  should 
bear  a  different  number  from  every  other  set  of  pieces,  each  number  being 
plainly  stamped  thereon,  so  that  if  several  instruments  of  the  same  pattern 
are  cleansed  at  once,  there  may  be  no  trouble  in  selecting  the  various 
pieces  belonging  to  any  particular  set. 


CARE  OF  SURGICAL    INSTRUMENTS 


19 


CARE  OF  SURGICAL  INSTRUMENTS. 

After  the  purchase  of  good  instruments  their  care  is  the  next  essential. 
Even  the  instruments  of  finest  manufacture  will  soon  become  worthless 
unless  properly  cleaned,  sharpened  and  stored  after  each  operation.  The 
formulating  of  cases  for  the  transportation  of  instruments  has  in  the  past 
been  an  important  matter  and  only  within  a  few  years  has  the  problem 
seemed  to  have  been  satisfactorily  solved. 

With  the  exception  of  cutting  instruments  and  pocket  case  sets,  solid 
boxes  either  of  metal  or  wood  are  seldom  employed.  They  not  only  add 
additional  weight  to  the  outfit  required  by  the  surgeon,  but  they  are  diffi- 
cult to  sterilize  besides  expensive  and  less  convenient.  Again,  they  do  not 
admit  of  the  addition  of  new  instruments,  a  matter  of  no  small  import. 
The  surgeon  cannot  say  to-day  what  combination  of  instruments  he  will 
require  a  year  hence,  and  as  the  arrangement  of  such  cases  cannot  be 
altered  every  time  an  instrument  becomes  obsolete  or  a  new  one  is  required, 
the  possessor  of  such  an  outfit  usually  foregoes  the  benefits  that  might 
accrue  by  necessary  changes. 

The  best  plan  for  caring  for  instruments  in  the  office  and  hospital  is  to 
provide  tight,  upright  cases  with  shelves  similar  to  book  cases;  they  should 


Figure  1.    Washable  Instrument  Roll. 

be  arranged  with  close  fitting  doors  and  of  material  that  will  admit  of  thor- 
ough cleansing.  They  may  be  of  metal  or  wood,  the  former  being  pre- 
ferred. Cases  of  this  character  are  fully  illustrated  in  a  chapter  devoted  to 
the  furnishing  of  the  operating-room,  to  which  the  reader  is  referred. 

For  the  general  storing  and  transporting  of  instruments,  no  better  plan 
has  been  devised  than  sterilized  cloth  rolls,  each  provided  with  loops  and  flaps 
and  so  constructed  that  they  may  be  rolled  into  a  compact  mass.  These 
pouches  or  covers  may  be  of  any  size  or  material,  soft  linen  being  pre- 
ferred. They  may  be  single  or  in  duplicate.  The  latter  plan  permits  the 
use  of  one.  while  the  other  is  being  washed  and  sterilized. 

Washable  Instrument  Rolls,  as  shown  by  figure  i,  are  designed  particu- 
larly for  gynecological  instruments.  Following  the  same  general  design 
they  may  be  constructed  for  instruments  in  almost  any  department  of  sur- 
gery. Where  knives  are  required  in  an  operating  set  some  form  of  shield 
is  necessary  that  the  edges  may  not  be  injured  by  contact. 

Instruments  after  use  should  be  thoroughly  cleaned  and  all  moisture 
carefully  removed.  Whenever  possible,  they  should  be  sterilized,  after 


20 


CARE   OF  SURGICAL  INSTRUMENTS. 


which  they  should  be  wiped  perfectly  dry  with  hygroscopic  sterile  gauze 
or  a  similar  fabric.  Instruments  should  under  no  circumstances  be  put 
away  while  moist  nor  should  they  be  inclosed  in  a  damp  receptacle. 

Cutting  instruments  should  always  be  handled  with  care  that  the  edges 
may  not  be  injured  by  contact.  Some  form  of  rack  like  those  described  by 
figure  327  is  advised  for  storage  purposes.  These  may  also  be  used  for 
transportation,  as  one  or  more  of  them  may  be  included  in  a  light  metal 
box,  where  the  edges  will  be  thoroughly  protected.  All  knives  should  be 
honed  before  use,  directions  for  which  will  be  found  in  connection  with 
figure  60 1. 


Figure  2.    Plain  Sheath  for  Knife  Blades. 

Plain  Sheaths  for  Knife  Blades  may  be  of  any  firm  material,  brass  nickel 
plated  or  stiff  leather  being  usually  preferred.  As  shown  in  figure  2,  they 
should  be  so  shaped  as  not  to  touch  the  knife  edge  and  sufficiently  stiff  to 
shield  the  latter  from  injury. 

Grady's  Knife  Shield  is  particularly  adapted  for  transporting  surgical 
knives  in  roll-up  pouches.  Trays  of  this  pattern  may  be  of  any  desired 
size  or  for  any  number  of  knives.  They  are  usually  manufactured  of  brass 
nickel  plated  and  so  thin  as  to  be  only  a  trifle  thicker  than  the  instrument 
protected.  As  shown  in  figure  3  the  blades  are  firmly  held  in  place  by  a 
sliding  plate,  lateral  displacement  being  prevented  by  properly  arranged 
clamps.  These  shields  are  so  constructed  that  they  may  be  immersed  for 
sterilization  without  removing  the  instruments. 


Figure  3.    Grady's  Shield  for  Knives  in  Sets. 

Metal  Knife  Cases  or  Boxes  similar  to  that  shown  in  figure  4  may  be 
constructed  for  any  number  of  knives,  those  for  four  and  six  blades  being 
usually  preferred.  They  may  be  supplied  with  hinged  or  telescoping 
covers  and  with  fixed  or  removable  racks.  Usually  the  knives  may  be 
sterilized  without  removing  them  from  the  case ;  this  is  an  advantage  in 
many  instances  as  it  prevents  injury  to  cutting  edges. 

Blunt  instruments,  particularly  those  which  when  in  use  are  brought 
into  contact  with  mucous  surfaces  should  be  kept  smooth  and  highly  pol- 
ished. Rubbing  with  fine  emery  paper  followed  by  polishing  with  rouge  is 
advised.  The  latter  may  be  obtained  from  surgical  instrument  dealers 
and  may  be  applied  with  chamois  skin  or  gauze,  preferably  the  latter  on 
account  of  cleanliness. 

Saw  blades  are  perhaps  the  most  difficult  instruments  to  keep  clean, 
sharp  and  free  from  rust.  A  saw  will  not  cut  well  if  the  wire  edge  is 
removed  from  the  teeth.  That  this  may  not  occur,  care  must  be  exercised 
that  emery  paper  or  similar  substance  is  not  used  to  remove  dirt  or  rust 


CARE  OF    SURGICAL  INSTRUMENTS. 


21 


spots  from  saw  teeth.  Where  rust  spots  occur,  the  blade  of  the  pocket  knife 
may  be  used  to  advantage  in  scraping  away  the  accumulation.  The  action 
of  the  knife,  however,  must  be  confined  to  the  space  occupied  by  the  rust. 
Saws  may  be  sharpened  by  three-cornered  files,  but  this  should  only  be 
attempted  by  those  who  have  had  experience  in  this  class  of  work. 

Silver  instruments  will  tarnish  or  turn  black  on  exposure  to  the  atmos- 
phere. They  are  best  kept  wrapped  in  dry  gauze  and  should  under  no 
circumstances  be  kept  long  in  contact  or  stored  with  rubber,  hard  or  soft. 


Figure  4.     Metal  Case  or  Box  for  Surgical  Knives. 

As  surgical  instruments  soon  deteriorate  unless  properly  cared  for,  not 
only  for  the  sake  of  economy  should  great  care  be  exercised  in  preserving 
appliances  of  this  character,  but  the  success  of  an  operation  frequently 
depends  on  the  proper  working  of  an  apparatus.  The  safety  of  patients 
and  the  purse  of  the  physician  are  alike  interested,  and  either  of  these  are 
of  sufficient  importance  to  demand  most  careful  attention. 

If  surgical  instruments  are  properly  cared  for  immediately  after  use, 
and  if  precautions  are  taken  to  preserve  them  from  all  forms  of  injury 
until  again  needed,  the  physician  will  many  times  save  himself  from  disap- 
pointment, be  able  to  give  better  service  to  his  patients,  and  have  less 
apparent  cause  for  complaint  against  instrument  makers. 

As  a  matter  of  fact,  the  latter  are  often  unjustly  criticised  and  accused 
of  constructing  inefficient  instruments,  when  the  fault  is  instead  due  to 
improper  use  or  lack  of  care  on  the  part  of  the  surgeon. 


CHAPTER  II. 


MECHANICAL  AIDS  IN  DIAGNOSIS. 

By  far  the  greater  portion  of  the  surgical  instruments  and  appliances 
employed  in  diagnosis  will  be  found  described  in  the  several  chapters 
devoted  to  regional  surgery.  For  instances,  the  ophthalmoscope  is  included 
in  the  section  devoted  to  ophthalmic  surgery,  throat  mirrors  in  laryngo- 
scopy,  etc.  Under  this  head  are  included  only  those  instruments  that  either 
could'not  be  classified  as  regional,  or  if  when  so  classified,  the  section  was 
found  to  contain  none  but  diagnostic  instruments.  These  consist  of  appli- 
ances for  microscopy,  centrifugal  sedimentation,  examination  of  blood,  ex- 
amination of  chest  and  lungs,  determination  of  body  temperature,  studying 
condition  of  pulse,  location  of  cranial  fissures,  exploration  of  tissue,  ascer- 
taining sensitiveness  of  skin,  locating  apex  beat  of  heart,  anthropometry, 
and  analysis  of  urine. 

MICROSCOPY. 

The  value  of  the  microscope  as  a  means  of  positive  diagnosis  is,  we 
believe,  so  fully  appreciated  as  to  require  no  comment  here.  It  is  em- 
ployed in  bacteriological  research,  examinations  of  urinary  sediments, 
blood  corpuscles,  pathological  products,  etc.  As  this  subject  is  fully  cov- 
ered in  many  small  hand  books  pertaining  to  microscopy,  the  reader  is 
referred  to  them  for  details. 

The  principal  features  in  the  construction  of  a  microscope  are  a  good 
stand,  high-class  objectives,  eye  pieces  with  a  proper  focusing  apparatus, 
a  good  condenser  and  suitable  reflecting  mirror. 

A  microscope  stand  should  be  firm,  free  from  tremor  and  of  accurate 
workmanship.  Steadiness  is  essential  and  may  be  secured  by  design, 
weight  or  a  combination  of  the  two.  For  general  use  a  stand  medium  in 
weight  but  with  a  broad  or  extended  base  will  pfbve  most  satisfactory. 
The  workmanship,  even  in  stands  of  low  power,  while  it  may  be  plain, 
should  be  good.  Accurate  adjustment  in  every  part  is  essential  because  a 
stand  should  be  of  a  quality  that  will  permit  the  use  of  high  power  object- 
ives. All  should  be  constructed  for  service  with  some  form  of  condenser, 
the  Abbe  type  being  generally  selected.  The  body  of  a  stand  consists  of 
two  tubes  telescoping  one  within  the  other  and  so  adjusted  that  the  extreme 
length  may  be  extended  or  shortened  as  required. 

The  focusing  arrangement  may  consist  of  the  body  tube  sliding  by 
rotary  hand  motion  within  a  sleeve,  or  it  may  be  adjusted  with  a  rack 
and  pinion  movement,  the  latter,  on  account  of  its  easier  and  more  accu- 
rate manipulation,  being  usually  preferred. 

Fine  adjustment  is  generally  secured  by  micrometer  screws,  the  latter 
consisting  of  a  fine  thread  acting  against  the  exerting  force  of  a  strong 
spring. 

A  good  stage    should    be    large    enough    to     admit    the    use    of    all 

22 


MICROSCOPY.  23 

necessary  accessories,  and  for  making  examinations  of  plate  cultures  under 
a  low  power  objective,  yet  not  so  thick  that  it  can  not  be  used  for  oblique 
illumination. 

Besides  the  ordinary  fixed  stage  there  are  two  special  forms  known  as 
the  mechanical  stage  and  the  sub-stage.  The  former  is  sometimes 
attached  to  a  fixed  stage  or  it  may  include  the  latter  in  its  construction. 
The  special  feature  of  the  mechanical  stage  consists  in  mechanism  by 
means  of  which  the  object  may  be  moved  in  any  direction,  vertically, 
laterally,  or  in  some  form  rotated,  by  means  of  rack  and  pinion  or  screw 
movements. 

The  substage  is  located  beneath  the  fixed  stage  and  is  employed  for 
holding  illuminating  or  polarizing  apparatus.  It  is  a  necessary  accessory 
where  high  power  objectives  are  used.  It  should  have  lateral  and  vertical 
movements,  each  part  working  evenly  and  smoothly,  and  should  by  all 
means  be  provided  with  mechanism  so  that  the  condenser  can  be  centered 
with  the  objective. 

The  mirror  underneath  the  stage  is  a  necessity  in  all  microscopes.  It  is 
usually  provided  with  plane  and  concave  surfaces. 

They  are  vised  to  illuminate  all  objects.  Many  are  so  constructed  that 
they  can  be  swung  above  the  stage  for  the  examination  of  opaque  bodies. 
All  should  be  arranged  with  double  movements,  one  permitting  the  mirror 
to  be  swung  at  various  angles  with  the  optical  axis  of  the  instrument,  the 
other  so  designed  that  it  may  be  adjusted  at  various  distances  from 
the  stage.  Aside  from  these  more  essential  qualifications  the  selection  of  a 
microscope  stand  is  like  buying  a  carriage  of  any  good  make ;  while  the 
purchaser  may  have  a  choice,  almost  any  will  answer  the  purpose. 

There  are  two  distinct  forms  of  microscopes  in  general  use  in  this 
country.  That  known  as  the  Jackson  type  and  the  Continental  model. 
The  former,  improved  by  American  inventors,  was  for  many  years  most  in 
use  but  is  now  rarely  employed.  Of  the  two  varieties  it  is,  however,  by  far 
the  most  convenient,  is  adapted  to  more  kinds  of  work  and  is  more  graceful 
in  appearance.  In  this  type  the  mirror  bar  is  so  constructed  that  the 
mirror  may  be  swung  above  the  stage. 

The  Continental  models  are  particularly  adapted  for  class  and  college 
work,  and  the  higher  grades  for  use  by  experts.  These  patterns  are  of 
heavy  construction,  low  and  compact  in  form  and  especially  designed  for 
use  while  in  a  vertical  position. 

The  impression  that  has  for  years  existed  in  the  minds  of  many  micro- 
scopists  that  it  was  necessary  to  send  to  Europe  in  order  to  obtain  a  good 
microscope  with  satisfactory  objectives,  has,  we  believe,  been  generally 
dissipated.  This  is  largely  due  to  the  efforts  of  The  Bausch  &  Lomb 
Optical  Co.,  Gundlach,  Zentmayer,  Spencer  and  others,  who  are  manufact- 
uring microscopes  and  accessories  that  are  the  equal  of  any.  It  is  certain 
that  instruments  and  objectives  of  American  manufacture  are  in  the  hands 
of  eminent  microscopists  who,  without  hesitation,  declare  them  equal  to 
any  made  in  the  Old  World. 

Without  attempting  to  illustrate  a  large  number  of  microscopes,  we  will 
include  a  few  of  the  more  popular  patterns,  those  we  believe  best  adapted 
for  general  use. 

Bausch  and  Lomb 's  Continental  Microscope  "BBS"  for  an  instrument 
of  low  price  meets  every  indication.  As  described  by  the  manufacturers, 
and  shown  by  figure  5,  "it  is  of  brass  throughout,  highly  polished  and 
lacquered.  Wherever  applicable,  the  corners  are  rounded,  making  the 


24 


MECHANICAL    AIDS    IN    DIAGNOSIS. 


instrument  pleasant  to  handle.  The  base  is  of  large  size,  with  ample  space 
for  manipulating  the  mirror  and  leaded  to  bring  the  center  of  gravity  as 
low  as  possible,  thus  giving  extreme  stability  at  any  angle  of  inclination  of 
the  arm.  The  stage  is  large,  with  a  hard  rubber  plate  vulcanized  into  its 
upper  surface  in  such  a  manner  as  to  prevent  warping.  The  substage  is 
adjusted  by  quick  acting  delicate  screw  motion,  and  may  be  swung  to  one 
side  when  not  in  use.  It  is  supplied  with  three  cylinder  diaphragms  of 
different  apertures.  The  mirrors  are  plane  and  concave,  of  large  size,  and 


Figure  5.     Bausch  &  Lomb's  Continental  Microscope  BBS. 

adjustable  to  obtain  the  best  illumination  under  different  sources  of  light. 
The  mirror  bar  has  a  stop  in  the  optical  axis.  The  joint  for  inclination 
has  large  bearings,  with  tapering  steel  axis  and  steel  stops  to  give  exactly 
the  horizontal  position.  Coarse  adjustment  is  by  diagonal  rack  and  pinion, 
the  rack  being  furnished  with  a  stop  to  prevent  jamming  the  pinion  teeth. 
The  fine  adjustment  is  by  micrometer  screw,  working  in  a  steel  nut  on  the 
triangular  bearing  of  the  arm.  The  head  of  the  micrometer  screw  is  grad- 


MICROSCOPY. 


25 


uated  and  silvered  and  provided  with  an  indicator.  The  draw  tube  is 
graduated  to  millimeters  and  nickel  plated.  It  slides  in  the  cloth  lined 
sleeve  of  the  main  tube.  When  set  at  145  mm.,  it  gives  the  short  standard 
of  tube  length  when  the  double  nose-piece  is  used." 

Bausch  and  Lomb's  Physician's  Microscope,  as  illustrated  by  figure  6,  is 
constructed  after  the  Jackson  model,   though  furnishing  many  improve- 


Figure  6.     Bausch  &  Lomb's  Physician's  Microscope. 

ments.  The  base  is  japanned  iron ;  pillar  and  arm  are  of  bronze,  connected 
by  a  joint  for  inclination  of  the  body.  Coarse  adjustment  is  by  diagonal 
rack  and  pinion,  giving  a  long  range;  fine  adjustment  by  micrometer 
screw,  acting  on  a  patent  movement.  The  main  tube  has  cloth  lining  and 
is  provided  with  a  cloth  lined  sleeve  tube  and  graduated  draw  tube.  The 


26  MECHANICAL    AIDS    IN    DIAGNOSIS. 

stage  consists  of  a  square  glass  stage  and  slide  carrier  attached  to  a  firm 
projecting  stage  plate.  The  mirror  bar  is  provided  with  adjustable  sub- 
stage,  carrying  dome  diaphragm,  and  plane  and  concave  mirrors.  It 
swings  on  its  axis  in  the  plane  of  the  stage  to  any  obliquity  below  or  above 
the  stage. 

Bausch  and  Lomb's  Continental  Microscope  "CCS  8"  is  adapted  for  the 
use  of  the  specialist  and  those  engaged  in  bacteriological  study.  As 
•described  by  the  manufacturers  and  illustrated  by  figure  7,  it  is  of  large  size, 


Figure  7.    Bausch  &  Lomb's  Continental  Microscope  CCS  8. 

jnade  of  brass  throughout,  highly  polished  and  lacquered.  Wherever 
practicable,  the  corners  are  rounded.  The  base  is  of  proportionately  large 
size,  giving  unusual  stability  at  any  angle  of  inclination,  with  a  large  space 
for  manipulating  the  mirror.  The  stage  is  circular,  of  large  size,  revolva- 
ble  and  has  hard  rubber  surface.  It  rests  upon  a  heavy  stage  plate,  pro- 
vided with  centering  screws  for  obtaining  exact  coincidence  with  the 
optical  axis,  and  within  narrow  limits  giving  a  mechanical  movement  for 


MICROSCOPY.  27 

the  object.  The  stage  is  easily  removable  when  it  is  desired  to  attach  the 
mechanical  stage.  The  entire  substage  is  adjustable  by  diagonal  rack  and 
pinion,  provided  with  improved  solid  bearings.  Large  plane  and  concave 
mirrors  are  supplied.  The  joint  for  inclination  is  provided  with  a  lever 
for  clamping  at  any  inclination.  The  coarse  adjustment  is  by  diagonal 
rack  and  pinion.  The  fine  adjustment  is  by  micrometer  screw  with  grad- 
uated and  silvered  head  with  an  indicator.  The  draw  tube  is  graduated 
in  millimeters,  and  nickel  plated  and  is  adjustable  in  the  cloth-lined 
sleeve  of  the  main  tube;  when  set  at  145  mm.,  it  gives  short  standard  of 
tube  length  when  the  double  or  triple  nose-piece  is  used. 

Objectives  and  Eye-Pieces. 

Objectives  should  be  of  good  quality,  even  if  the  stand  is  of  inferior 
grade.  The  essential  features  of  an  objective  are  clearness  of  definition, 
flatness  of  field  and  power  of  resolution.  At  least  two  are  necessary,  one 
of  low  power  for  plate  illustrations,  the  second  one  of  high  power,  prefer- 
ably to  be  used  by  immersion.  The  latter  are  required  in  many  cases 
where  minute  organisms  or  details  are  to  be  closely  studied.  They  are 
also  necessary  for  bacteriological  investigation. 

It  should  be  borne  in  mind  that  the  value  of  an  objective  does  not 
depend  upon  the  number  of  times  it  will  magnify.  An  objective  of  cheap 
construction  may  be  of  high  magnifying  power,  though  almost  worthless  for 
working  purposes.  If  the  purchaser  is  limited  to  a  small  investment,  an 
inch  or  a  three-quarter  inch  for  low  power  and  a  one-fifth  or  one-sixth  inch 
for  high  power  may  be  selected ;  later,  if  conditions  warrant,  a  one-tenth 
or  a  one-twelfth  immersion  lens  may  be  added  to  his  outfit. 

The  selection  of  good  dry  objectives  is  of  the  utmost  importance,  as  a 
large  percentage  of  the  work  of  the  physician  should  be  performed  with 
them.  They  may  be  obtained  of  any  desired  strength  from  a  focus  of  three 
or  five  inches  to  that  of  one-eighth,  the  higher  powers  usually  being 
adjustable  to  various  thicknesses  of  cover  glasses. 

Immersion  Lenses  are  now  selected  almost  exclusively  where  high  pow- 
ers are  required.  They  were  formerly  used  with  water,  but  now  are 
employed  with  oil,  as  this  furnishes  clearer  images.  The  oil  used  should  be 
thickened  cedar  oil.  These  lenses  may  be  procured  in  strengths  varying 
from  one  fourth  to  one  twenty-fifth  of  an  inch.  The  one-twelfth,  however, 
is  the  most  practical  and  in  fact  all  that  is  required  in  actual  work. 

Eye-Pieces  may  be  of  various  strengths;  they  are  sometimes  used  to 
increase  the  magnification.  While  this  is  practicable  with  low  power 
objectives,  it  cannot  be  employed  to  advantage  with  high  powers  unless 
they  are  of  the  best  quality.  Generally  speaking,  the  securing  of  a  high 
magnifying  power  by  means  of  eye-pieces  is  at  the  expense  of  good 
definition. 

Accessory  Apparatus. 

For  the  examination  of  objects  more  or  less  apparatus  is  necessary.  For 
a  detailed  description  of  each  article  the  reader  is  referred  to  any  good  hand- 
book on  microscopy.  Those  selected  for  illustration  and  description  here 
consist  of  condensers,  diaphragms,  nose-pieces,  camerae  lucidae,  and  mi- 
crometers. 

Condensers. 

These  consist  of  a  series  of  lenses  arranged  to  concentrate  the  light  to  a 
further  extent  than  can  be  accomplished  by  a  concave  mirror  alone.  They 


28  MECHANICAL    AIDS   IN    DIAGNOSIS. 

should  be  constructed  so  as  to  project  upon  the  object  the  largest  possible 
cone  of  light  that  is  free  from  spherical  and  chromatic  aberrations. 


Figure  8.    Abbe  Condenser  with  All  Necessary  Parts  in  Position  for  Central  Illumination. 

The  Abbe  Condenser  shown  by  figure  8  comprises  lenses  of  short  focus 
and  of  such  size  as  to  utilize  nearly  all  the  rays  of  light  passing  through 
the  substage  ring.  Usually  they  are  manufactured  in  two  forms,  a  double 
and  triple  combination,  the  former  suited  to  objectives  of  medium  aper- 
ture, the  latter  to  those  of  the  largest  aperture.  The  volume  of  light 
secured  with  either  is  sufficient  for  any  amplification.  The  cone  of  light 
may  best  be  reduced  when  necessary  for  the  examination  of  stained 
specimens  by  the  use  of  an  iris  diaphragm.  In  the  best  instruments  there 
is  an  iris  below  the  condenser  that  limits  the  angle  and  volume  of  light 
at  the  same  time  and  also  an  iris  above  the  condenser  in  the  plane  of  the 
stage  to  limit  the  volume  without  decreasing  the  angle. 

Diaphragms. 

These  are  employed  to  change  or  regulate  the  amount  of  light  directed 
upon  the  object.  They  may  be  made  with  fixed  or  closing  apertures,  the 
latter  being  usually  preferred. 


Figure  9.    Iris  Diaphragm. 


The  Iris  Diaphragm,  as  illustrated  by  figure  9,  consists  of  a  number  of 
pivoted  blades,  all  arranged  to  act  simultaneously,  so  that  the  circular  central 


MICROSCOPY. 


29 


opening  may  be  decreased  or  enlarged  at  will  by  lever  movement.  As  this 
pattern  gives  almost  universal  satisfaction,  it  has  superseded  nearly  all  other 
devices. 

Plain  Diaphragms  consist  of  rotating  discs,  each  containing  a  series  of 
apertures,  all  arranged  to  be  carried  into  the  optical  axis.  They  possess  one 
advantage  in  that  the  apertures  being  fixed,  a  satisfactory  illumination  may 
often  be  duplicated  after  having  been  changed  by  diaphragm  movement. 
This  form,  however,  is  seldom  used  except  on  low-priced  stands. 

Micrometers. 

These  are  employed  for  measuring  microscopical  objects.  Among  the 
various  forms  some  one  of  the  following  types  are  usually  selected: — 


Figure  10.    Eye-Piece  Micrometer. 


Figure  11.    Filar  Micrometer. 


The  Eye-Piece  Micrometer  consists  of  a  transparent  arbitrary  scale  inserted 
into  an  ordinary  Huyghenian  eye-piece  so  adjusted  that  the  ruling  of  the 
scale  will  rest  in  the  focus  of  the  eye-piece  lens  and  in  the  same  -plane  as 
the  magnified  image  under  observation.  As  this  method  is  far  from  accu- 
rate, its  only  advantage  is  the  low  price  of  the  accessory.  It  is  exhibited  by 
figure  10. 

The  Filar  Micrometer,  as  illustrated  by  figure  1 1 ,  is  designed  for  accurate 
measurements.  It  consists  of  two  or  more  delicate  cross-hairs,  adjusted  by 
sensitive  micrometer  screws.  The  cross-hairs  and  magnified  object  are 
compared  by  means  of  a  Ramsden  eye-piece,  the  latter  forming  part  of  the 
apparatus.  The  micrometer  screw  controlling  the  longitudinal  cross-hair 
is  of  great  delicacy  and  precision.  It  is  moved  by  a  milled  wheel,  the 
latter  carrying  a  disc,  the  circumference  of  which  is  accurately  graduated 
by  a  scale  divided  into  one  hundred  parts.  A  small  comb  provided  with 
teeth  is  placed  in  the  lower  portion  of  the  field  serving  to  record  the  revolu- 
tions of  the  screw.  This  apparatus  is  particularly  recommended  to  those 
who  require  great  accuracy  in  measurements.  In  using  it  the  operator 
must  know  the  exact  proportion  existing  between  the  size  of  the  object 
and  its  magnified  image. 

Nose-Pieces. 

These  consist  of  mechanism  by  means  of  which  one  objective  may  be 
substituted  for  another.  They  are  used  principally  in  cases  where,  after 
finding  a  particular  object  on  the  slide,  it  is  desirable  to  submit  it  to  higher 
amplification  withoiit  otherwise  disarranging  the  focal  combination.  A 
nose-piece  facilitates  this  change  without  danger  of  misplacing  the  object 
from  the  microscopical  field.  It  is  also  a  time-saving  device,  as  different 
powers  may  be  at  hand  for  instant  use,  and  there  is  no  danger  of  dropping 
the  lenses  when  changing  from  one  to  the  other. 


30 


MECHANICAL    AIDS    IN    DIAGNOSIS. 


The  Double  and  Triple  Revolving  Nose-Pieces  shown  by  figures  1 2  and  1 5 
are  the  most  useful  patterns,  because  by  simple  rotation  any  one  of  the 
objectives  selected  may  be  carried  by  the  arm  to  which  it  is  attached  into 


Figure  12.    Double  Revolving  Nose-Piece.  Figure  13.    Triple  Revolving  Xose-Piece. 

the  optical  axis.  The  angular  patterns  are  preferred  to  the  straight  varie- 
ties, because  in  using  the  latter  there  is  always  danger  of  contacting  some 
portion  of  the  stage  or  other  parts  by  the  rotating  objectives. 

Camerae  Lucidae. 

These  consist  of  means  for  projecting  the  magnified  image  upon  a 
surface  for  drawing  or  projecting  an  image  of  the  pencil  and  paper  into 
the  microscopic  field.  They  are  employed  for  securing  accurate  tracings 
of  the  object  under  inspection,  either  for  illustrations,  future  reference  or 
measurements. 


Figure  14.    Beale's  Camera  Lucida. 


Figure  15.    Double  Prism  Camera  Lucida. 


Beale's  Camera  Lucida,  as  shown  by  figure  14,  consists  of  a  piece  of  tinted 
glass  as  devised  by  Beale,  mounted  in  a  hard  rubber  frame  so  that  its  sur- 
face rests  at  an  angle  of  45  degrees  with  the  optical  axis  of  the  microscope. 
By  a  proper  adjustment  the  magnified  image  and  the  pencil  point  may  be 
seen  projected  on  a  paper  at  the  same  time.  Thus  an  accurate  sketch  can  be 
prepared.  This  pattern  has  the  disadvantage  of  producing  an  inverted 
image,  requiring  that  it  be  traced  on  thin  paper  and  the  latter  turned  for 
examination. 

The  Double  Prism  Camera  Lucida,  as  exhibited  by  figure  15,  consists  of  a 
combination  of  lenses  so  arranged  as  to  show  at  the  same  time  the  micro- 
icopical  image,  the  pencil  point  and  the  paper  all  clearly  and  within  the 
same  field  of  vision,  the  whole  being  so  well  defined  that  an  accurate  trac- 
ing may  be  made.  If  the  work  becomes  tiresome,  it  may  be  stopped  for  an 
sndefinite  period;  and  if  no  change  be  made  in  adjustment,  recommenced 


MICROSCOPY. 


31 


at  any  time.     It  may  be  used  with  the  microscope  in  an  upright  or  an  in- 
clined position. 

Preparation  and  Mounting  of   Objects. 

The  necessary  material  for  the  preparation  of  mounted  slides  embraces 
nearly  if  not  all  the  following  articles:  Section  cutter,  glass  slides  upon 
which  to  secure  objects,  slide  immersion  trough,  cover  glasses,  cover  glass 
gauge  for  measuring  thicknesses,  cover  glass  cleaner,  cover  glass  holders, 
lifters,  etc.,  turn  table. 

Section  Cutters. 

Some  form  of  a  cutter  is  necessary  for  obtaining  thin  sections  of  many 
of  the  substances  to  be  examined.  These  may  consist  of  razors,  knives  or 
special  instruments  called  microtomes. 


Figure  16.     Microscopical  Razor. 

Section  Knives  consist  of  blades  with  thin  sharp  edges.  Usually  the 
under  face  of  the  blade  is  flat.  They  may  be  folding  of  the  ordinary  razor 
pattern  or  with  stiff  handles  like  an  amputating  knife. 

The  Microscopical  Razor,  as  shown  by  figure  16,  differs  from  those  em- 
ployed for  shaving  in  being  constructed  with  one  flat  face,  and  is  ground 
to  a  fine  cutting  edge. 

Solid  Handle  Section  Knives,  as  shown  by  figure  17,  may  be  obtained  of 
various  lengths  of  blades ;  those  are  usually  preferred  which  have  a  cutting 
surface  of  from  5  to  8  inches.  Like  the  pattern  previously  referred  to,  at 
least  one  surface  must  be  flat.  Usually  in  order  to  obtain  a  thin  edge,  the 
opposite  surface  is  concave. 


Figure  1™.     Solid  Handle  Section  Cutter. 

Microtomes  consist  of  devices  for  securing  a  mechanical  feed  whereby 
thin  layers  of  a  known  but  uniform  thickness  may  be  secured.  They  may 
comprise  holding  and  feed  mechanism  only,  or  may  be  constructed  with 
knives  moving  in  guides,  and  with  or  without  attachments  for  freezing. 

Bastin's  Hand  Microtome  consists  of  a  cylindrical  body  that  contains  the 
clamp  for  holding  the  object  and  the  micrometer  screw  for  elevating  the 
object-carrier.  A  glass  disc,  mounted  for  protection  in  a  metal  frame,  is 
fastened  to  the  top  of  the  body  and  forms  the  cutting  plate  over  which  the 
knife  moves.  The  head  of  the  micrometer  screw  forms  a  cap  for  the 
lower  end  of  the  body  cylinder  and  is  graduated  to  ten  parts.  As  the  pitch 
of  the  screw  is  o.  5mm.,  the  graduations  read  to  o.osmm.  The  micrometer 
screw  is  entirely  inclosed  and  protected  from  injury.  The  object  carrier 


32 


MECHANICAL    AIDS    IN    DIAGNOSIS. 


has  a  movement  of  i8mm.  The  specimen  is  firmly  fixed  in  the  clamp 
by  a  screw  with  milled  head.  All  the  metal  parts  are  nickeled  to  prevent 
injury  from  reagents. 

The  Small  Table  Microtome,  shown    in   figure    19,   is  one  of   the  best 
low-priced  instruments.     The  frame  of  this  microtome  is  a  single  casting, 


Figure  18.    Bastin's  Hand  Microtome. 


Figure  19.    Small  Table  Microtome. 


which  forms  the  cutting  plate  and  support  for  the  object  holder.  Two  polished 
glass  plates  are  attached  to  the  upper  surface  of  the  frame  and  form  the 
guide  for  the  knife.  The  object  clamp  has  vertical  and  limited  lateral 
adjustment,  by  means  of  the  post  attaching  the  jaws  to  the  slide  piece.  The 
feed  is  by  accurate  micrometer  screw,  of  o.  5  millimeter  pitch,  the  head  be- 
ing graduated  into  100  parts,  permitting  reading  to  0.005  millimeter.  The 
object  carrier  has  a  vertical  movement  of  18  millimeters  by  means  of  the 
micrometer  screw.  This  microtome  is  a  very  useful  one  for  botanical  and 
histological  work,  cutting  frozen  sections,  etc. 


Figure  20.    Bausch  &  Lomb's  Laboratory  Microtome. 

Bausch  and  Lomb's  Laboratory  Microtome,  as  illustrated  by  figure  20,  is 
one  of  the  most  satisfactory  in  use  among  this  class  of  instruments.  Me- 
chanically it  consists  of  three  parts,  the  stand  proper,  the  knife  block  and  the 
carriage.  The  stand  is  a  solid  casting,  insuring  firmness  and  rigidity.  This 


MICROSCOPY. 


33 


contains  a  removable  metal  pan  that  is  used  for  collecting  any  drip  from  the 
knife.  The  knife  block  slides  on  three  parallel  plane  surfaces  and  is  so 
arranged  as  to  secure  uniformity  of  motion  and  to  prevent  displacement 
of  the  knife.  The  latter  is  clamped  to  the  upper  surface  of  the  block  in 
such  a  way  as  to  permit  its  adjustment  to  any  angle  with  the  object  or  any 
position  on  the  block.  The  carriage  is  a  stirrup-shaped  solid  casting,  mov- 
able along  the  whole  front  of  the  microtome  stand.  A  clamp  enables  the 
operator  to  secure  it  firmly  at  any  desired  point.  Its  sliding  mechanism  is 
such  that  the  object  may  be  perfectly  adjusted  to  the  knife,  and  the  whole 
edge  of  the  knife  brought  into  service  when  desired.  A  special  arm  is 
arranged  to  slide  vertically,  allowing  the  object  to  be  elevated  or  depressed 
in  front  of  the  knife  edge  as  desired.  The  feed  is  by  a  sensitive  micrometer 
screw.  The  thread  of  this  screw  is  cut  with  great  accuracy,  the  pitch  be- 
ing 0.5  millimeters.  The  disc  attached  to  the  micrometer  screw  is  gradu- 
ated and  divided  into  500  parts,  its  margin  being  cut  into  notches,  each  of 
which  represents  two  divisions  of  the  field.  The  feed  mechanism  is  so 
regulated  that  successive  sections  of  uniform  thickness  may  be  cut.  The 
apparatus  may  be  employed  for  any  class  of  work  for  which  a  microtome 
should  be  used. 

Glass  Slides. 

Slides  for  mounting  objects  consist  of  strips  of  thin  glass  usually  one 
inch  in  width  by  three  in  length.  Glass  for  this  purpose  should  be  free 
from  air  bubbles,  striae  or  other  flaws  and  of  a  clear,  transparent  quality. 
Flint  glass  is  iisually  employed,  but  that  known  as  patent  plate  is  largely 
used  by  experts. 


Figure  21.    Microscopical  Glass  Slides, 
with  Cut  Edges. 


Figure  22.     Microscopical  Glass  Slides, 
with  Ground  Edges. 


Figure  23.     Microscopical  Glass  Slide, 
with  Concave  Center. 


Figure  24.    Microscopical  Glass  Slide, 
with  Beveled  Edges. 


The  edges  of  these  slides  may  be  either  cut  or  ground,  the  latter  being 
preferred.  The  thickness  of  the  slide  should  depend  on  the  nature  of  the 
object  and  the  focal  distance  and  aperture  of  the  lens  employed.  The 
thinner  slides  are  used  for  mounting  objects  which  require  high  power 
objectives  and  achromatic  condensers,  while  the  medium  and  thicker  grades 
are  used  for  ordinary  objects. 

The  varieties  of  slides  usually  found  in  the  market  consist  of  green 
glass  with  cut  or  ground  edges,  white  glass  with  cut,  ground  or  beveled 
edges,  patent  plate  (extra  thin)  with  ground  edges  and  wood  for  opaque 
objects. 


34 


MECHANICAL    AIDS    IN    DIAGNOSIS. 


Slide  Immersion  Trough. 

While  slides  may  be  properly  cleansed  in  any  convenient  utensil  by 
washing  in  soda  or  potash  solutions,  a  special  vessel  will  prove  of 
advantage. 


Figure  25.    Slide  Immersion  Trough. 

The  Slide  Immersion  Trough,  portrayed  in  figure  25,  consists  of  a  small 
glass  box  of  oblong  form  and  of  such  size  as  to  readily  hold  a  quantity  of 
glass  slides.  They  may  be  obtained  with  or  without  covers. 

Cover  Glasses. 

These  consist  of  sheets  of  thin  glass  of  such  form  and  size  as  may  be 
necessary  to  protect  the  mounted  object.  They  may  be  of  any  desired 
thickness  from  .002  to  .01  of  an  inch.  The  glass  may  be  procured  in  sheets 
and  cut  as  wanted,  or  procured  in  circles,  squares  or  oblongs  of  any  desired 
size.  As  it  is  not  annealed,  it  is  hard  and  brittle,  and  for  this  reason  difficult 
to  cut  by  any  but  experts.  It  is,  therefore,  usually  purchased  ready  for  use. 


Figure  86.    Square  Glass  Covers 
for  Microscopical  Objects. 


Figure  27.    Circular  Glass  Covers 
for  Microscopical  Objects. 


The  Cover  Glasses  found  in  the  market  are  usually  known  as  numbers 
i,  2  and  3.  The  first  is  used  with  objectives  of  high  power  and  is  usually 
about  .  004  of  an  inch  in  thickness.  The  number  2  is  employed  for  general 
work  and  is  about  .006  of  an  inch  in  thickness;  while  the  number  3  is  .020 
of  an  inch  in  thickness  and  is  employed  for  very  low  power  objectives  if  at 
all.  The  thinner  varieties,  those  .003  and  .002  of  an  inch  in  thickness,  are 
suitable  for  oil  immersion  lenses  only.  As  nearly  all  dry  lenses  are  cor- 
rected for  number  2  cover  glasses,  the  use  of  thinner  or  thicker  ones  inter- 
feres with  their  defining  power. 

The  sizes  generally  carried  in  stock  by  dealers  are  as  follows: 

Circles  or  squares     No.   o  Extra  thin 

"     l  T£T  to  TOT*  °f  an  mcn  in  thickness 
ii       ii         it  «  f  „     i      nit     «>      it         o 

2  rH  to  jitf 

II  "  II  II  1  A.  |  it  II  II  II  II 

3  Stf    to  TW 

In  diameters  of  ^,  s/8t  ^,  ^  or  i  inch. 
Rectangular  of  same  numbers  and  of  any  size. 


MICROSCOPY. 


35 


Cover  Glass  Gauge. 

The  thickness  of  cover  glasses  may  be  measured  by  any  fine  caliper,  but 
preferably  by  special  instruments  called  cover  glass  gauge. 

The  Cover  Glass  Gauge,  expressed  in  figure  28,  consists  of  two  micrometer 
screws  contained  within  a  shaft,  each  occupying  the  same  line  of  axis.  To 
one  of  the  screws  a  wheel  is  attached,  upon  the  periphery  of  which  various 
graduations  are  marked.  By  placing  a  cover  glass  between  the  ends  of  the 


Figure  28.    Cover  Glass  Gauge. 


Figure  29.    Dallinger's  Cover  Glass  Cleaner. 


two  micrometer  screws  and  bringing  the  end  of  the  movable  one  in  contact 
with  the  glass,  the  thickness  of  the  latter  will  be  noted  on  the  drum  in 
thousandths  of  an  inch  and  hundredths  of  a  millimeter. 

Cover  Glass  Cleaners. 

While  cover  glasses  may  be  cleaned  by  ordinary  finger  manipulation, 
owing  to  their  small  size  and  fragile  character,  an  appliance  for  facilitating 
such  work  is  of  advantage. 

Dallinger's  Cover  Glass  Cleaner,  as  shown  by  figure  29,  consists  of  two 
hard  wood  cones,  the  apex  of  each  being  formed  into  a  suitable  handle. 
The  base  of  each  should  be  perfectly  flat  and  covered  with  soft  leather  of 
uniform  thickness.  This  should  be  stretched  over  the  surface  like  a  drum 
head  and  held  in  place  by  a  ring  encircling  the  whole.  Cover  glasses 
slightly  moistened  may  be  cleaned  and  wiped  between  the  two  leather 
surfaces,  after  which  they  may  be  stored  in  absolute  alcohol  or  other 
medium. 

Cover  Glass  Holders,  Lifters,  Etc. 

Owing  to  the  extreme  delicacy  of  cover  glasses,  some  form  of  holder  or 
lifter  is  necessary  for  their  manipulation. 

Self-Closing  Cover  Glass  Forceps,  as  shown  by  figure  30,  consist  of  a  strip 
of  spring  brass  shaped  to  form  a  cross  action  clip.  As  they  are  usually 
constructed  from  thin  material,  the  spring  is  delicate  and  under  easy  con- 
trol. The  blades  are  wide,  with  smooth  rounded  surfaces,  so  there  is  little 
if  any  danger  of  crushing  a  cover  glass  held  in  the  jaws.  As  the  instru- 
ment is  inexpensive,  it  commands  a  large  sale. 


36 


MECHANICAL    AIDS   IN    DIAGNOSIS. 


Linyer's  Cover  Glass  Forceps,  as  exhibited  by  figure  31,  present  advan- 
tages which  we  believe  are  not  found  in  any  other  instrument.  It  consists 
of  a  slender  self-closing  spring  forceps  of  light  construction  and  delicate 
force.  The  blades  are  so  shaped  that  when  the  forceps  rest  upon  the  table 
top,  the  tip  of  the  blades  and  any  inclosed  cover  are  slightly  elevated  above 
the  table  surface. 


Figure  30.    Self-Closing  Cover  Glass  Forceps. 

In  order  to  secure  a  firm  grasp,  the  tip  of  each  blade  is  provided  with 
three  teeth,  the  center  tooth  of  each  jaw  pointing  upward  or  inward  and 
the  two  outer  pointing  downward  and  outward.  The  cover  glass  is  easily 
grasped  between  the  jaws  of  this  instrument  as  is  well  shown  in  the  illus- 
tration. An  additional  advantage  is  the  placing  of  the  jaws  in  such  a  man- 
ner that  the  cover  glass  does  not  rest  horizontally  but  in  an  inclined  position 
where  it  may  drain  when  required. 

Turn  Tables. 

These  consist  of  small  circular  revolving  discs  or  tables  arranged  with 
mechanism  for  holding  the  slide  upon  which  an  object  is  to  be  mounted. 
They  are  employed  not  only  for  cementing  the  slide,  object  and  cover 
glass,  but  for  applying  the  cement  in  forming  circles  surrounding  the 
mounted  body,  building  round  cement  cells,  etc. 

The  National  Turn  Table,  as  expressed  in  figure  32,  consists  of  a  small 
oblong  iron  table  with  round  ends  and  provided  with  three  legs,  one  of 


Figure  31.    Linyer's  Cover  Glass  Forceps. 

which  forms  the  base  for  a  shaft  carrying  a  revolving  disc,  the  latter  form- 
ing a  portion  of  the  table  top.  This  disc  is  provided  with  spring  clips  by 
means  of  which  a  slide  may  be  firmly  held  in  any  desired  position.  Small 
circles  in  the  center  of  the  disc  are  used  as  guides  in  centering  and  apply- 
ing cover  glasses  and  constructing  cement  cells. 

A  hand  rest  about  half  as  large  as  the  table  top  projects  above  the 
latter  and  extends  part  way  over  the  revolving  disc. 

Preparation  and  Mounting  of  Objects. 

The  following  list,  while  far  from  complete,  is  intended  to  include  the 
articles  most  necessary  in  the  preparation  and  mounting  of  microscopical 
objects:  — 


MICROSCOPY  37 

Alcohol,  both  commercial  and  absolute,  is  required  for  cleaning  slides 
and  in  the  preparation  of  various  objects  and  of  mounting  material. 

Turpentine  of  pure  quality  is  used  for  cleansing  purposes,  for  saturating 
many  kinds  of  objects  before  mounting  and  for  preservation  of  objects. 

Benzol  is  employed  as  a  solvent  for  many  of  the  aniline  dyes,  as  well  as 
to  dissolve  resin,  fats,  oils,  etc. 

Paraffine  is  largely  used  as  an  embedding  substance,  either  as  an  exter- 
nal support  to  a  mass  as  a  whole  or  as  a  penetrating  substance  to  hold  the 
tissues  of  an  object  in  proper  position. 

Canada  Balsam  is  the  oleo-resin  taken  from  the  Pinus  Canadensis.  It 
is  used  for  general  cementing  purposes  in  all  but  glycerine  mounts. 

Xylol  Balsam  composed  of  equal  parts  of  xylol  and  Canada  balsam  is 
used  as  a  preservative. 

Gold  Size  is  the  ordinary  preparation  used  by  painters.  In  mi- 
croscopical work  it  is  generally  employed  for  cementing  purposes,  not  only 
for  fastening  objects  to  the  slides,  but  also  for  cementing  the  cover  glasses 
to  them. 

Asphalt  Varnish  is  made  by  dissolving  pure  asphaltum  in  mineral 
naphtha.  It  is  used  for  making  shallow  cement  cells  and  for  finishing  speci- 
mens after  being  fastened  with  gold  size  or  balsam. 


Figure  32.    National  Turn  Table. 

Brunswick  Black  may  be  obtained  from  artists'  supply  houses.  It  is 
used  where  a  black  back  is  desired. 

Aniline  in  various  colors,  blue,  green,  Bismarck's  brown,  blue  black, etc., 
are  largely  used  as  stains.  They  may  be  procured  in  powder  form  or  in 
solutions  ready  for  use.  Among  these  methyl  blue,  methyl  violet,  gentian 
violet,  and  Bismarck's  brown  are  particularly  used  for  staining  bacteria  in 
tissues. 

Fuchsin  (hydrochlorid  of  rosaniline)  is  much  used  in  double  or  multiple 
staining.  Gruber's,  a  German  preparation,  is  recommended  as  being  the 
best. 

In  addition  to  the  above,  the  chemicals  and  glassware,  and  other  appa- 
ratus necessary  in  mounting  and  preparing  objects,  according  to  Reeves, 
may  comprise : — 

i  Curved  Pointed  Forceps,  i  Curved  Sharp-pointed  Scissors, 

i  Dozen  Small  Test  Tubes,  i  Dozen  Pipettes, 

i  Spirit  Lamp,  2  Books  Litmus  Paper,  one  each  red 

i  Water  Bath  and  Oven,  and  blue, 

•   3  Funnels,  i,  3  and  6  ounces,  2  Graduates,  i  and  8  ounces, 

6  Narrow-mouth  Glass  Stoppered  6  Wide-mouth  Glass  Stoppered  Bot- 

Bottles,  2  ounces,  ties,  6  or  8  ounces, 

6  Boxes,  each  to  hold  25   slides,     i  Drop  Bottle. 


38 


MECHANICAL    AIDS    IN     DIAGNOSIS. 


CENTRIFUGAL   SEDIMENTATION. 


Centrifugal  sedimentation  may  be  secured  by  the  centrifuge,  which 
consists  of  mechanism  by  means  of  which  two  arms,  each  bearing  a  tube 
containing  the  fluid  to  be  examined,  are  rotated  in  a  horizontal  plane  at  a 
speed  sufficient  to  cause  a  rapid  sedimentation  of  solid  organic  or  inorganic 
particles  in  the  fluid  by  centrifugal  force.  It  is  employed  for  the  volu- 
metric examination  of  blood,  and  the  sedimentation  of  urine,  sputum,  etc. 
The  instrument  is  a  time-saver  when  compared  with  old  style  slow  and 
inefficient  apparatus. 

We  are  indebted  to  Purdy  for  many  improvements  in  the  development 
and  construction  of  these  machines.  Among  his  inventions  are  the  conical 


Figure  33.     High  Gear  Centrifuge  Machine. 

urine  sedimentation  tubes,  the  metallic  guards, '  or  sheaths,  by  which 
these  are  prevented  from  breaking,  better  appliances  for  the  handling  of 
micro-organisms  after  sedimentation,  and  methods  for  easy  concentration 
of  comparatively  large  quantities  of  blood. 

The  speed  obtained  by  the  revolving  arm  of  a  machine  is  in  proportion 
to  its  radius.  High  speed  with  short  arms  should  not  mislead  the  pur- 
chaser, because  the  centrifugal  force  developed  in  a  given  tube  increases 
as  the  square  of  the  radius,  the  speed  being  the  same.  The  centrifugal 
force  may  then  be  represented  by  the  speed  multiplied  by  the  square  of 
the  radius. 

The  power  employed  may  be  hand  crank,  electric  or  a  counter  shaft, 
the  first  mentioned,  though  less  efficient,  being  more  commonly  utilized. 
Mechanically  the  hand  centrifuge  consists  of  a  series  of  gear  wheels  so 
arranged  that  one  revolution  of  the  crank  will  result  in  from  50  to  100 


CENTRIFUGAL     SEDIMENTATION. 


39 


revolutions  of  the  shaft.  This  number  varies  with  different  manufacturers. 
Electric  machines  are  constructed  with  a  speed  as  high  as  eight  to  ten 
thousand  revolutions  per  minute,  but  generally  speaking  this  high  rate  of 
speed  is  not  essential. 

In  addition  to  the  crank,  gear  and  clamps  for  attaching  the  instrument 
to  the  table  or  other  fixture,  nearly  all  the  forms  of  this  instrument  ter- 
minate in  an  upright  shaft,  arranged  at  its  top  for  attachment  to  either 
a  hematokrit  or  tube  carrier  for  urine  sedimentation.  The  hematokrit 
attachment  consists  of  two  glass  graduated  blood  tubes,  each  fitting  in  a 
metallic  frame,  together  with  a  pipette  and  suction  tube. 

These  tubes  are  usually  about  fifty  mm.  in  length,  five  mm.  in  diameter 
bore  and  are  marked  with  a  scale  from  o  to  100.  In  some  tubes  the  scale 
is  constructed  with  a  magnifying  front. 

By  the  aid  of  this  instrument,  undiluted  blood  may  be  separated  or 
defibrinated,  the  red  corpuscles,  which  have  the  greater  specific  gravity, being 
thrown  to  the  peripheral  extremity  of  the  tube,  the  white  corpuscles,  which 
have  a  less  specific  gravity,  will  rest  immediately  inside  of  the  red  division ; 
while  the  plasma,  or  liquor  sanguinis,  occupies  the  remainder  of  the  tube 


Figure  34.    Urinary  Centrifuge. 

space,  the  latter  usually  being  clear  and  free  from  corpuscles.  The  better 
forms  of  tubes  are  accurately  calibrated  in  tenths  of  a  cubic  cm.  up  to  the 
IQCC.  mark.  Purdy  advises  an  additional  graduation  to  15  cc. ,  the  extra 
5  cc.  being  divided  into  fourths,  the  latter  to  be  used  to  measure  any 
reagents  used  in  precipitation. 

Metal  guards  or  sheaths  for  the  glass  tubes  are  essential,  for  only  with 
them  can  high  speed  be  safely  obtained.  Aluminum  was  first  employed 
for  this  purpose  because  of  its  extreme  lightness.  This  has  been  super- 
seded by  brass  in  the  construction  of  many  machines  because  the  former 
metal  was  found  to  deteriorate  rapidly  when  employed  for  this  purpose. 

Purdy,  who  designed  these  guards,  states  that  careful  examination  has 
demonstrated  that  in  uranalysis  where  acid  solutions  are  employed,  the 
centrifugal  force  is  so  great  as  to  cause  some  of  the  liquid  to  penetrate  the 
cells  of  the  glass,  and  attack,  and  ultimately  destroy,  the  tip  of  the  alumi- 
num guard. 

Nearly  all  instruments  of  this  class  are  provided  with  attachments  for 
the  examination  of  sputum  from  patients  supposed  to  be  tuberculous,  asth- 
matic, etc.  The  earlier  tedious  methods  of  boiling  and  diluting  are 


40 


MECHANICAL    AIDS    IN     DIAGNOSIS. 


avoided.  Not  only  are  specimens  for  microscopical  use  quickly  obtained 
by  means  of  this  instrument,  but  they  are  more  highly  concentrated  and 
more  accurately  represent  the  fluid  from  which  they  have  been  taken. 

The  High  Gear  Centrifuge  consists  of  suitable  gear  wheels,  crank,  clamp 
and  upright  shaft  by  means  of  which  any  desired  speed  may  be  obtained. 
As  shown  by  figure  33  the  apparatus  consists  of  two  glass  urine  tubes, 
plain ;  one  urine  tube  graduated  in  tenths  from  one  tenth  to  ten  cubic  cen- 
timetres. This  is  used  for  the  immediate  quantitative  analysis  of  the 
chlorides,  phosphates,  sulphates,  albumin,  blood,  pus,  etc.  ;  two  metal  re- 
ceptacles for  the  urine  tubes;  one  pipette;  one  hematokrit  attachment, 
comprising  two  graduated  sedimentation  tubes,  fitting  into  a  metallic  frame ; 
two  plain  tubes  for  sputum,  pus,  etc. ,  arranged  for  attachment  to  the  hem- 
atokrit frame,  and  one  suction  tube  for  filling  the  blood  and  sputum  tubes. 
With  this  combination  an  analysis  may  be  quickly  made  of  urine,  blood, 
sputum,  etc. 


Figure  35.    Purdy's  Electrical  Centrifuge. 

The  Urinary  Centrifuge  is  designed  somewhat  on  the  principle  of  the 
one  last  described,  but  is  of  cheaper  construction  and  geared  for  a  lower  rate 
of  speed.  As  exhibited  by  figure  34,  it  is  designed  exclusively  for  urinary 
analysis  for  which  use  it  answers  every  purpose.  The  attachments  consist 
of  two  urine  tubes,  two  metal  receptacles  for  same,  one  urine  tube  grau- 
ated  in  tenths  cc.,  and  one  pipette. 

Electric  Centrifuges  are  now  designed  for  use  with  almost  any  electrical 
current,  whether  constant  or  interrupted,  or  from  storage  or  primary  bat- 
teries. Once  properly  installed,  they  furnish  most  satisfactory  appliances, 
for  with  them  almost  any  desired  rate  of  speed  may  be  obtained.  A  speed 
indicator,  with  a  proper  rheostat,  is  a  necessary  attachment  to  machines  of 
this  class. 

Purdy's  Electrical  Centrifuge,  as  exhibited  by  figure  35,  is  arranged  so 
as  to  maintain  a  speed  varying  from  500  to  10,000  revolutions  per  minute, 


EXAMINATION    OF    BLOOD.  41 

the  tips  of  the  tubes  describing  a  circle,  the  radius  of  which  is  6^  inches.  It 
can  be  operated  by  ordinary  incandescent  lighting  currents  of  any  voltage; 
each  machine,  however,  must  be  specially  wound  for  the  current  in 
which  it  is  to  be  placed.  With  it  one  ounce  of  urine  may  be  carried  2,500 
revolutions  per  minute;  if  provided  with  a  double  arm  holding  four  tubes, 
it  will  carry  two  ounces  1,600  revolutions  per  minute. 

For  micro-organic  examinations  special  tubes  are  provided  that  may  be 
carried  10,000  revolutions  per  minute  on  a  radius  of  4^  inches.  Special 
tubes  are  provided  for  the  concentration  of  micro-organisms.  These  con- 
sist of  conical  tubes  of  ice.  capacity,  open  at  both  ends,  and  are  filled 
with  the  fluid  to  be  examined.  The  large  end,  after  filling,  may  be  closed 
with  a  slender  soft  rubber  cork,  while  the  small  or  peripheral  end  rests 
against  a  rubber  washer.  By  centrifugal  force  any  micro-organisms  present 
in  the  fluid  may  be  condensed  into  that  portion  of  the  container  occu- 
pying the  outer  or  small  end  of  the  tube.  By  removing  the  latter 
from  the  metallic  frame  in  which  it  is  held  while  in  motion  and  making 
plight  inward  pressure  on  the  soft  rubber  cork  previously  referred  to,  a 
single  drop  or  fraction  thereof  may  be  expressed  from  the  tip  of  the  tube 
and  deposited  directly  on  a  slide  for  examination.  This  apparatus  may  be 
procured  with  attachments  for  blood  and  urine  examinations  either  sepa- 
rate or  combined. 

EXAMINATION  OF  BLOOD. 

The  character,  relative  proportions  of  red  and  white  corpuscles  and 
chemical  changes  in  the  blood,  may  usually  be  determined  by  one  or  more 
of  the  following  methods:  Counting  the  corpuscles;  examining  the  percen- 
tage of  hemoglobin  present,  or  spectroscopy. 

Blood  Corpuscles  may  be  counted  by  the  use  of  the  microscope,  aided  by 
some  means  of  computation  whereby  the  actual  or  approximate  number  of 
each  form  may  be  determined.  The  appliances  employed  for  this  purpose 
are  usually  called  hemocytometers. 

Hemocytometers. 

Hemocytometers  consist  of  apparatus  for  diluting  the  blood  and  count- 
ing the  contained  corpuscles. 

The  Thoma-Zeiss  Hemocytometer  is  the  variety  in  most  common  use.  As 
exhibited  by  figure  36  ?  it  consists  of  a  slender  glass  capillary  tube  or  pipette 
ten  centimeters  long,  expanded  just  above  its  center  in  the  form  of  a  bulb 
or  reservoir,  the  latter  containing  a  small  movable  glass  ball.  A  rubber 
tube  may  be  attached  to  the  pipette  by  means  of  which  it  can  be  filled  and 
emptied.  The  tube  is  graduated  with  a  scale  from  o.  i  to  101,  the  res- 
ervoir being  about  one  hundred  times  the  capacity  of  the  capillary  tube 
leading  to  it. 

The  remainder  of  the  apparatus  consists  of  a  slide  and  special  cover 
glass,  the  former  constructed  with  a  containing  cell  i-io  mm.  in  depth,  the 
floor  of  which  is  divided  by  fine  lines  into  squares,  each  square  equaling 
1-4000  mm.  These  squares  are  separated  into  groups  by  deeper  or  heavier 
lines.  The  blood  to  be  tested  should  be  drawn  into  the  capillary  tube 
until  the  latter  is  filled  to  the  mark  i.  A3  per  cent,  solution  of  chloride 
of  sodium  or  a  10  per  cent,  solution  of  sodium  sulphate  is  added  to  the  tube 
until  the  latter,  including  the  bulb,  is  filled  to  the  mark  101.  The  tube  is 
then  closed  with  a  rubber  cap,  or,  as  suggested  by  some  writers,  with  the 


42 


MECHANICAL    AIDS     IN     DIAGNOSIS. 


finger,  and  shaken  until  thoroughly  mixed.  In  the  latter  process  the  mov- 
able glass  bulb  serves  to  incorporate  the  blood  with  the  saline  solution.  If 
it  is  desired  to  count  the  leucocytes,  also,  the  saline  solution  may  be  slightly 
tinged  with  methyl  violet,  by  means  of  which  these  may  be  separately 
determined.  After  being  thoroughly  mixed,  one  half  of  the  fluid  should  be 


Figure  36.    Thoma-2eiss  Hemocytometer. 

blown  from  the  bulb,  when  a  single  drop  may  be  deposited  on  the  floor  of 
the  previously  cleaned  counting  cell,  after  which  the  cover  glass  should  be 
placed  over  the  cell.  The  slide  must  be  kept  level  and  all  the  conditions, 
as  stated  in  the  directions  accompanying  the  apparatus,  carefully  complied 
with.  The  counting  may  be  done  by  the  aid  of  a  good  microscope  with  a 
one-quarter  or  one-fifth  inch  objective.  As  each  square  represents  1-4000 


Figure  37.    Gower's  Hemocytometer. 

of  a  cubic  millimeter,  and  as  the  blood  is  diluted  one  hundred  times,  compu- 
tation is  easy  and  approximately  correct. 

Other  solutions  than  the  above  are  used  with  this  apparatus.  Care  must 
be  taken  that  the  tube  be  carefully  cleaned  before  use,  employing  distilled 
water,  alcohol,  ether,  and  a  current  of  air  in  succession. 

Gower's  Hemocytometer,  as  illustrated  by  figure  37,  consists  of  a  small 
pipette,  a  capillary  tube,  a  small  glass  jar,  a  stirring  rod  a  needle  or  lance, 


EXAMINATION    OF    BLOOD.  43 

and  a  brass  stage  plate.  The  pipette  is  graduated  to  hold  995  cubic  mm. 
It  is  constructed  with  a  mouth-piece  and  rubber  tubing,  by  means  of  which 
it  may  be  filled  and  emptied. 

The  capillary  tube,  when  filled  to  the  mark  on  the  stem,  contains  five 
cubic  mm. ,  and  is  also  supplied  with  a  mouth- piece  and  rubber  tubing.  The 
dilution  may-be  made  in  the  small  glass  jar,  and  the  stirring  rod  employed 
to  thoroughly  incorporate  the  blood  in  the  solution.  The  brass  stage  plate 
contains  a  glass  slide  in  the  center  of  which  is  a  special  cell  1-5  mm.  deep. 
The  bottom  of  this  cell  is  divided  into  small  i-io  mm.  squares.  The  cell 
is  protected  by  means  of  a  cover  glass  held  in  place  with  two  metal  springs 
attached  to  the  ends  of  the  stage  plate. 

As  ordinarily  employed  a  solution  of  sodic  sulphate  to  the  amount  of 
995  cubic  mm.  is  thoroughly  mixed  with  5  cubic  mm.  of  blood  in  the  small 
vessel  by  means  of  the  stirring  rod. 

A  portion  of  this  solution  is  placed  in  the  cell,  the  cover  glass  applied, 
and  the  whole  transferred  to  a  microscopic  stage.  After  the  corpuscles 
have  been  allowed  to  settle,  the  numbers  contained  in  any  one  or  more 
squares  may  be  counted  by  properly  focusing  the  instrument. 

The  Quantity  of  Hemoglobin  in  a  given  specimen  of  blood  may  be  deter- 
mined by  means  of  hemometers,  hemoglobinometers,  centrifuges,  etc. ,  the 
latter  described  on  page  38. 

Hemometers,  Hemoglobinometers,  Etc. 


Figure  38.    Fleischl's  Hemometer. 

Fleischl's  Hemometer,  as  shown  by  figure  38,  is  constructed  on  the  prin- 
ciple that  a  sample  of  diluted  blood  may  be  compared  with  a  glass  wedge 
colored  with  Cassiu's  golden  purple  or  some  other  similar  pigment.  It 
consists  of  a  platform,  or  stage,  with  a  circular  opening  similar  in  form  to 
that  found  in  the  ordinary  microscope.  The  under  portion  of  the  stage  is 
movable  and  contains  a  mounted  red  glass  wedge  through  which  a  beam  of 
artificial  light  (natural  light  cannot  be  used)  is  projected  from  a  plaster  of 
paris  reflector  located  beneath  the  stage. 

Above  the  circular  opening  in  the  platform  and  exactly  over  the  glass 
wedge  a  tube  i  y2  cm.  in  diameter  is  securely  fastened.  The  bottom  is 


44 


MECHANICAL    AIDS     IN     DIAGNOSIS. 


closed  with  a  plate  of  glass,  while  a  vertical  metallic  partition  divides  it 
into  halves  in  such  a  manner  that  one  side  is  lighted  through  the  glass 
wedge,  while  the  other  receives  its  light  through  the  glass  forming  the 
bottom  and  reflected  by  the  plaster  of  paris  plate.  The  former  division 
is  filled  with  distilled  water,  while  the  latter  is  filled  with  the  blood  to  be 
examined,  the  latter  being  properly  diluted.  The  glass  portion  is  graduated 
to  a  scale,  ranging  from  o  at  its  thinner  end  to  120  at  its  thickest  portion. 
This  may  be  moved  by  a  rack  and  pinion  movement ;  by  a  comparison 
of  colors  the  quantity  of  hemoglobin  present  may  be  approximately  deter- 
mined. 


Figure  39.    Gower's  Hemoglobinometer. 

Gower's  Hemoglobinometer,  as  exhibited  by  figure  39,  consists  of  two 
tubes  of  equal  size,  a  pipette,  a  guarded  lancet  or  needle,  and  a  drop  bot- 
tle with  rubber  cap.  One  of  the  tubes  is  closed  and  contains  a  solution  of 
picrocarmine-glycerine,  the  color  of  which  corresponds  to  a  i  per  cent, 
solution  of  normal  blood.  This  is  used  for  comparison.  The  graduated 
tube  open  at  the  top  should  contain  about  134  divisions,  each  holding  20 
cubic  mm.  of  fluid.  Into  this  a  small  quantity  of  distilled  water  is  placed, 
to  which  the  blood  to  be  tested  is  added.  After  the  puncture  is  made  with 
the  lancet,  the  blood  may  be  drawn  into  the  pipette  until  20  cm.  are 
obtained.  This  may  then  be  placed  in  the  test  tube  and  distilled'  water 
added  by  means  of  the  drop  bottle  until  the  color  of  the  mixture  corres- 


Figure  40.    Browning's  Spectroscope. 

ponas  to  that  in  the  test  vial.  The  number  indicated  on  the  scale  at  the 
height  of  the  fluid  in  the  tube  will  denote  the  approximate  percentage  of 
hemoglobin.  Great  cleanliness  should  be  observed  in  carrying  out  every 
detail. 

Spectroscopic  Examination  of  the  Blood  is  employed  in  certain  cases  to 
determine  chemical  changes  in  the  blood.     The  necessary  instruments  are 


EXAMINATIONS    OF    CHEST    AND    LUNGS.  45 

called  spectroscopes.     They  are  constructed  both  for  use  with  the  micro- 
scope and  by  hand. 

Browning's  Spectroscope,  as  traced  in  figure  40,  consists  of  two  lens  bear- 
ing tubes  in  telescopic  form.  By  the  latter  arrangement  a  correct  focus 
may  be  obtained.  By  means  of  a  series  of  prismatic  and  other  lenses  a  cor- 
rect spectrum  may  be  secured. 

EXAMINATIONS  OP  CHEST  AND  LUNGS. 

Such  appliances  as  are  generally  employed  for  making  examinations  of 
the  chest  and  lungs,  may  be  classified  as  instruments  for  mensuration, 
auscultation,  percussion  and  paracentesis.  The  last  mentioned  will  be 
found  described  in  a  special  chapter. 

Mensuration. 

Instruments  for  mensuration  may  be  divided  into  those  used  to  deter- 
mine the  circumference  of  the  chest;  amount  of  circular  expansion  or 
respiratory  motion ;  comparative  size  and  shape  of  both  sides ;  vital  or  air 
capacity  and  air  pressure. 

The  Circumference  of  the  Chest  may  be  determined  by  an  ordinary  tape 
line.  While  linen  tape  will  answer  the  purpose,  the  steel  tape  is  preferable. 

Tape  Measures. 

Tape  Measures  may  be  procured  of  various  lengths,  3,  4,  5  or  6  feet,  the 
two  latter  sizes  being  usually  preferred.  As  the  French  system  of  measure- 
ment is  so  frequently  employed,  tape  measures  for  this  purpose  should  con- 
tain the  English  scale  upon  one  side  and  the  French  system  upon  the  other. 


Figure  41.    Tape  Measure  With  Linen  Band.  Figure  42.    Tape  Measure  With  Steel  Band. 

Figure  41  shows  the  ordinary  measure  with  linen  tape,  while  figure  42 
exhibits  one  with  a  steel  tape. 

The  Amount  of  Respiratory  Motion  or  circular  expansion  exhibited  during 
ordinary  or  forced  expiration  and  inspiration  may  be  determined  by  the 
use  of  a  tape  line  or  a  special  instrument  called  a  stethometer. 

Stethometers. 

These  consist  of  some  form  of  registering  scale,  or  dial,  by  means  of 
which  the  varying  circumferences  of  the  chest  may  be  noted. 

Quain's  Stethometer  consists  of  a  small  circular  case  containing  a  coiled 
spring,  a  drum  arranged  with  watch-like  mechanism  and  a  dial,  or  index. 
The  adjustment  is  such  that  a  cord  passing  around  the  chest  and  attached 
to  the  drum  will  cause  a  hand  to  move  back  and  forth  around  the  dial. 
Each  inch  of  increase  or  decrease  in  the  circumference  of  the  chest  is  indi- 
cated by  one  revolution  of  the  hand.  This  is  well  sketched  in  figure  43. 

Carroll's  Stethometer  consists  of  a  slotted  plate  marked  with  a  scale  of 
three  inches  and  provided  with  an  indicator  projecting  through  the  slot  and 


46 


MECHANICAL    AIDS     IN     DIAGNOSIS. 


serving  as  a  marker.  To  the  end  of  the  indicator,  as  illustrated  by  figure 
44,  a  tape  line  is  attached,  from  the  proximal  end  of  which  enough  has  been 
cut  so  that  when  it  is  attached  to  the  instrument  scale,  the  measurement 
is  continuous.  When  the  instrument  is  applied,  this  tape  passes  around  the 
chest  where  it  may  be  fastened  in  a  catch  provided  in  the  near  end  of  the 
scale  for  that  purpose.  If  the  tape  be  tightened  during  expiration,  the 


Figure  43.    Quain's  Stethometer 

for   Measuring  Amount  of 

Respiratory  Motion. 


TIEMANN  &CQ  6     • 

* 

Figure  44.    Carroll's  Stethometer  for  Determining  the  Extent 
of  Respiratory  Motion. 


amount  of  expansion  on  full  inspiration  will  be  marked  by  the  indicator.  A 
small  flattened  band  of  metal  placed  around  the  scale  in  front  of  the  hand 
or  marker,  will  render  the  instrument  self-registering.  By  means  of  a 
delicate  rubber  band  attached  to  two  projecting  arms,  one  upon  the  fixed 
and  the  other  upon  the  movable  portion  of  the  instrument,  the  indicator 
may  be  caused  to  slide  backward  and  forward  with  the  movement  of  the 
chest  walls. 

The  Comparative  Size  and  shape  of  the  sides  of  the  chest  may  be  deter- 
mined by  some  form  of  curved  caliper,  ordinary  pelvimeters  being  fre- 
quently used  for  this  purpose. 

Pelvimeters. 

Pelvimeters  consist  of  two  arms  united  with  a  hinged  joint  and  provided 
with  a  graduated  scale  by  which  the  distance  between  arm  terminals  may 
be  determined.  Additional  patterns  will  be  found  described  in  the  chapter 
devoted  to  obstetrical  surgery. 

Billing's  Modification  of  Baudeloque's  Pelvimeter,  as  portrayed  by  figure 
46,  consists  of  a  pair  of  straight  hinged  shafts,  or  shanks,  terminating  in 
long  semi-circular  shaped  arms.  The  tips  of  the  arms,  while  presenting  a 
flat  point  of  contact  with  each  other,  are  provided  with  short  projecting 
horizontal  points,  that  they  may  not  slip  when  pressed  against  the  skin. 

Cyrtometers. 

These  usually  consist  of  some  form  of  curved  caliper  provided  with  flexi- 
ble arms  by  which  the  shape  of  the  outer  chest  wall  may  be  ascertained 
and  transferred  to  paper. 

Flint's  Cyrtometer,  as  shown  by  figure  45,  consists  of  a  caliper  with  short 
steel  arms  to  the  ends  of  which  strips  of  bar  lead  are  attached  by  means  of 
set  screws.  These  soft,  pliable  parts  form  the  contact  portion  of  the  in- 
strument. A  curved  bar,  or  indicator,  attached  to  one  arm  rests  in  and 
slides  through  a  slot  in  the  opposite  arm.  A  thumb  screw  fixes  the  arms 
at  any  degree  of  separation.  The  cross  bar  is  graduated  so  it  can  be  reset 
at  any  given  position.  By  fixing  the  instrument  at  the  proper  width,  the 
outline  of  one  side  of  the  chest  may  be  accurately  molded  in  the  lead  bars, 
the  set  screw  released  and  the  instrument  removed,  after  which  by  replac- 


EXAMINATIONS    OF    CHEST    AND    LUNGS. 


47 


ing  the  arms  in  the  same  relation  to  each  other,  the  outline  may  be 
accurately  traced  upon  paper.  A  second  outline  similarly  taken  upon  the 
opposite  side  will  show  an  accurate  comparison.  In  the  absence  of  the 
above  instrument,  some  one  of  the  appliances  used  in  orthopedic  measure- 
ments and  described  in  that  section  may  be  employed. 

Spirometers. 

The  Air  or  Vital  Capacity  of  the  chest  may  be  determined  by  various 
forms  of  instruments,  those  resembling'  gasometers  being  usually  employed. 
They  may  be  constructed  either  on  the  tank  principle  or  on  that  of  an  ordi- 
nary house  gas  meter.  Those  on  the  tank  principle  may  be  of  two  forms, 
that  of  the  common  storage  tank  used  by  gas  companies  or  an  expandible 
chamber,  into  either  of  which  the  air  is  forced  by  expiration. 

Barnes'  Spirometer,  as  outlined  by  figure  48,  consists  of  a  compressible 
cylindrical  bag  contained  within  a  metallic  chamber.  The  ends  of  the  bag 
are  of  wood  or  of  other  light  yet  firm  material.  Each  of  these  ends  is 
provided  with  an  opening  in  its  center  through  the  lower  one  of  which  the 


Figure  45.    Flint's  Cyrtometer. 


Figure  46.    Billing's  Modification  of 
Baudeloque's  Pelvimeter. 


expired  air  is  forced.  If  the  bag  be  in  a  collapsed  condition,  that  is  with 
both  ends  in  close  contact,  when  air  is  forced  into  the  receiver,  the  upper  or 
movable  one  will  raise  under  the  air  pressure.  A  metallic  graduated 
cylinder  projecting  upward  through  the  chamber  and  attached  to  the 
upper  end  of  the  air  bag,  marks  the  cubic  contents  of  the  latter  so  that  the 
amount  of  air  forced  into  the  chamber  may  be  noted  at  any  time.  This 
cylinder  is  provided  with  a  valve  at  its  upper  terminal  through  which  the 
air  may  be  allowed  to  escape  while  the  bag  is  being  compressed.  As  the 
instrument  is  entirely  surrounded  by  metal,  it  is  durable  and  presents  a 
neat  appearance. 

Denison's  Spirometer,  as  illustrated  by  figure  47,  consists  of  a  small  accor- 
dion-shaped reservoir,  supplied  with  an  upright  sliding  bar  and  gauge  which 
shows  any  degree  of  elongation  that  may  be  produced  by  air  forced  into 
the  chamber.  As  it  is  manufactured  from  soft  rubber  in  a  collapsible  form 
and  light  in  construction,  little  force  is  lost  by  the  contractile  power  or 
weight  of  the  movable  portion  of  the  instrument,  and  it  therefore  offers 
little  resistance  to  expiration. 


48 


MECHANICAL    AIDS     IN     DIAGNOSIS. 


It  is  accurately  adjusted  so  that  it  shows  the  amount  of  the  expired  air 
in  cubic  inches.  An  exhaust  valve  facilitates  the  emptying  of  the  instru- 
ment, and  the  frame  by  means  of  which  it  is  held  in  position  is  so  arranged 
that  it  may  be  taken  apart  for  transportation  when  desired.  A  table  show- 
ing the  standard  vital  capacity  of  individuals  of  various  heights,  both  male 
and  female,  is  furnished  with  each  instrument. 

The  Amount  of  Air  Pressure  may  be  determined  by  various  instruments, 
the  manometer  being  probably  the  best  known. 


Figure  47.    Denison's  Spirometer. 


Figure  48.    Barnes'  Spirometer. 


Manometer. 


Figure  49.    Denison's 
Manometer. 


Denison's  Manometer,  as  traced  in  figure  49,  consists  of  an  inverted  "U" 
shaped  glass  tube,  both  ends  of  the  latter  terminating  in  bulbs  of  about  y2 
oz.  capacity.  The  tube  is  securely  fastened  to  a  wood  base  to  which  a  scale 
is  attached.  When  arranged  for  use,  mercury  is  poured  into  one  of  the 
bulbs  until  it  equals  in  height  the  point  on  the  scale  marked  O.  To  the 
opposite  bulb  a  rubber  tube  and  mouth-piece  are  attached.  By  blowing 
into  the  instrument  during  forced  expiration,  the  amount  of  depression  of 
the  column  of  mercury  is  shown  by  the  scale,  registering  in  pounds  press- 
ure the  force  of  the  lungs.  The  bulbs  are  necessary  in  the  construction 
of  this  instrument  in  order  that  the  mercury  may  not  be  forced  out  of  the 
end  of  the  tube.  Small  curved  inlet  tubes  prevent  any  accidental  outflow 
during  transportation. 

Auscultation. 

Auscultation,  if  mediate,  requires  some  form  of  appliance  for  conduct 
ing  the  sound  waves  to  the  ears  of  the  examiner.      Instruments  for  this 
purpose  are  called  stethoscopes,  phonendoscopes,  etc. 


EXAMINATIONS    OF    CHEST    AND    LUNGS. 


49 


Stethoscopes. 

Stethoscopes  are  usually  tubular  in  form  and  may  be  adapted  for  use 
in  one  or  both  ears,  the  latter  being  generally  employed.  As  a  rule  all  are 
so  constructed  that  they  may  be  used  in  examinations  of  the  heart.  They 
may  be  classified  as  single,  double,  compound  and  phonendoscopic. 

Single  or  Monaural  Stethoscopes  consist  of  conductors  arranged 
to  convey  the  sound  waves  to  one  ear  of  the  listener.  They  may  be  rigid 
or  flexible.  Single  rigid  stethoscopes  usually  consist  of  hollow  cylinders 
with  expanded  endings,  that  one  to  be  placed  over  the  ear  being  much 
larger  in  circumference  than  the  pectoral  tip.  Of  the  various  materials  used 
in  their  manufacture,  wood  is  usually  preferred. 


Figure  50.     Hawksiey's  Stethoscope. 

Hawksley's  Stethoscope  consists  of  a  flattened  disc  of  bone,  hard  rubber 
or  similar  material,  having  an  opening  in  its  center  connecting  with  a  hol- 
low metallic  cylinder  that  terminates  in  a  small  conical-shaped  cup  about 
i  inch  in  external  diameter.  In  many  patterns  like  that  depicted  in  figure 
50,  the  base  or  large  disc  may  be  unscrewed  for  transportation. 

The  Separable  Stethoscope,  delineated  in  figure  51,  comprises  a  large  size 
disc  to  which  may  be  attached  a  shaft  forming  the  main  body  of  the  instru- 
ment. The  latter  is  separable  into  two  parts  by  means  of  a  threaded  joint 
in  the  center.  A  flat  bar  with  perforations  attached  to  the  upper  portion 
of  the  disc  forms  a  holder  for  the  two  sections  of  the  tube,  as  shown  in  the 
illustration. 


Figure  51.     Separable  Stethoscope. 


Figure  52.    Telescoping  Stethoscope. 


The  Telescoping  Stethoscope,  as  exhibited  by  figure  52,  does  not  differ 
materially  from  the  pattern  of  Hawksley  except  that  it  is  separable  in  the 
center  of  the  shaft,  one  half  being  small  and  telescoping  within  the  other. 

The  Plain  Cedar  Stethoscope,  outlined  by  figure  53,  consists  of  a  hollow 
cylinder  as  above  described,  usually  from  6  to  7  inches  in  length.  The 
smaller  tip  is  generally  about  i  inch,  and  the  larger  from  i^  to  2  inches  in 
external  diameter. 

Arnold's  Single  Elastic  Stethoscope  consists  of  a  pectoral  tip  about  i^  in- 
ches in  diameter,  connecting  by  means  of  elastic  web-covered  hose  with 
a  suitable  ear  ending.  The  only  advantage  possessed  by  the  instrument 
is  its  elasticity.  This  pattern,  once  popular  in  Europe,  now  commands 
only  a  limited  sale.  It  is  exhibited  by  figure  54. 

Double  or  Binaural  Stethoscopes  consist  of  conductors  that  convey  the 
sound  waves  simultaneously  to  both  ears.  They  usually  consist  of  a  forked 


50 


MECHANICAL    AIDS    IN     DIAGNOSIS. 


t 

stem  connecting  with  two  curved  auricular  tubes  by  means  of  short  pieces 
of  elastic  hose.  The  curved  tubes  are  generally  of  metal,  hinged  or  united 
with  some  form  of  spring  joint  at  their  lower  extremities.  They  are 
so  shaped  as  to  press  firmly  against  the  outer  margin  of  the  external 
meatus,  being  held  in  close  contact  by  means  of  an  elastic  tape  or  some 
form  of  spring.  The  auricular  ends  terminate  in  bulb-shaped  tips  of  such 
size  and  shape  that  they  will  fill  the  external  canal,  excluding  all  outside 
sound  waves.  The  rigid  or  metallic  portion  must  be  of  such  shape  as  to 
conduct  the  sound  waves  into  and  not  against  the  side  of  the  auditory  canal. 
The  ear  tips  must  be  of  a  size  to  fit  the  operator,  and  unless  they  are  of 


Figure  53.    Plain  Cedar  Stethoscope. 


Figure  54.    Arnold's  Single  Elastic 
Stethoscope. 


the  proper  shape  the  instrument  becomes  worthless.  Two  or  more  chest 
pieces  are  usually  provided,  one,  a  small  one  for  making  examinations  of 
the  heart.  This  tip,  according  to  different  authorities,  may  vary  from 
Y^  of  an  inch  to  i  inch  in  external  diameter. 

Soft  rubber  pectoral  tips  are  advised  by  some  operators,  particularly  in 
making  examinations  of  emaciated  patients.  This  is  because  the  soft  rub- 
ber can  be  made  to  fit  closely  over  uneven  surfaces.  It  is  claimed,  however, 
that  the  movements  of  the  soft  rubber  portion  at  the  point  of  connection 
or  junction  with  the  firmer  material  produces  a  grating  sound  which  is 
liable  to  mislead  the  operator. 

In  some  patterns  spiral  springs  are  employed,  by  means  of  which  the 


Figure  55.    Camman's  Stethoscope. 


arms  of  the  stethoscope  are  held  firmly  in  the  ears.  These,  it  is  said,  are 
objectionable,  because  the  breath  of  the  surgeon  or  patient  coming  in  con- 
tact with  the  spiral  wire  causes  it  to  vibrate,  and  thus  produces  misleading 
sounds. 

Care  should  be  exercised  in  the  selection  of  a  stethoscope  to  procure  a 
pattern  that  is  not  only  a  good  conductor  and  well  constructed,  but  one  that 
will  properly  fit  the  ear  of  the  examiner. 

A  second  class  of  binaural  stethoscope  is  called  differential.  These  are 
constructed  by  uniting  two  flexible  stethoscopes,  that  sounds  may  be  con- 
ducted to  the  ears  simultaneously  from  two  different  portions  of  the  chest. 


EXAMINATIONS    OK    CHEST    AND    LUNGS. 


51 


By  removing  first  one  and  then   the  other  chest-piece,  any  difference  in 
sound  may  be  detected. 

Camman's  Stethoscope.  In  its  lightest  form  of  construction  this  instru- 
ment consists  of  two  metallic  arms  connected  by  a  hinged  joint,  the  tubes 
being  held  in  contact  with  the  ears  by  means  of  an  elastic  tape.  This  por- 
tion of  the  stethoscope  is  connected  with  a  forked  tip  by  means  of  two  silk- 
covered  elastic  tubes.  To  the  pectoral  end,  one  of  two  hard  rubber  tips  may 
be  attached,  the  one  about  an  inch  in  diameter  for  making  examinations  of 
the  heart,  the  other  bell-shaped  about  i-M?  inches  in  diameter  for  examina- 
tions of  the  chest.  An  additional  soft  rubber  tip  often  accompanies  these 
instruments.  It  is  attached  to  the  instrument  by  being  slipped  over  the 
large  end  of  the  small  heart  tip.  This  is  well  illustrated  with  the  above- 
mentioned  tips  by  figure  55. 


Figure  56.    Knight's  Stethoscope. 

Knight's  Stethoscope  does  not  differ  materially  from  the  pattern  of  Cam- 
man  before  described.  The  principal  change  is  in  the  form  of  the  spring, 
which  in  this  case  is  spiral,  acting  on  two  levers  in  the  form  of  a  toggle  joint. 
This  change  in  the  manner  of  securing  ear  pressure  on  the  tips  is  outlined 
by  figure  56. 


Figure  57.    Snofton's  Stethoscope. 


Snof  ton's  Stethoscope,  as  defined  in  figure  57,  is  probably  one  of  the  light- 
est and  most  simple  of  binaural  stethoscopes.  It  consists  of  two  metallic 
ear  tubes  of  small  diameter,  united  by  a  single  piece  of  spring  steel,  the 
spring  serving  not  only  to  hold  the  tubes  together,  but  to  keep  the  tips 
firmly  pressed  into  the  external  canal.  The  flexible  portion  of  this  instru- 
ment consists  of  ordinary  rubber  tubing.  The  forked  piece  is  of  metal, 
provided  with  a  single  hard  rubber  bell-shaped  tip  about  1^6  inches  in 
diameter.  As  the  instrument  is  soft  and  folds  into  small  space,  it  can  be 
conveniently  carried  in  the  pocket.  Its  sound-transmitting  quality  is 
limited  by  its  method  of  construction,  the  small  caliber  flexible  rubber 
hose  being  inferior  for  this  purpose. 

LLUlil 


52 


MECHANICAL    AIDS     IN     DIAGNOSIS. 


Corwin's  Stethoscope,  as  exhibited  in  figure  58,  while  of  the  Camman 
type,  possesses  many  advantages  over  the  ordinary  pattern.  The  improve- 
ments consist  in  a  folding  device,  a  substitution  of  soft  rubber  for  the  semi- 
flexible  tubes  formerly  used  and,  a  double-ending  reversible  chest  piece 
that  may  be  used  for  either  chest  or  heart  examination.  The  auricular 
tubes  at  their  proximal  endings  are  widely  separated  that  they  may  not 


Figure  58.    Corwin's  Stethoscope. 

press  too  closely  against  the  face.  They  are  united  by  a  hinged  lock  in 
such  a  manner  that  they  may  be  turned  until  they  rest  side  by  side.  Heavy 
soft  rubber  hose  with  a  lumen  the  same  as  the  internal  diameter  of  the 
tubes  and  ear  tips,  connects  the  auricular  portion  with  a  bifurcated  metallic 
end  to  which  the  double-ended  bell  is  attached.  As  before  stated,  the  lat- 
ter by  reversing  may  be  either  small  or  large. 


Corwin's  Stethoscope  Folded. 


The  Laennec  Stethoscope,  devised  by  Bartlett,  belongs  to  the  heavier  class 
of  stethoscopes,  the  instrument  throughout  being  stronger  than  those  of 
the  ordinary  Camman  pattern.  As  exhibited  by  figure  59,  the  forked  piece 
of  the  stethoscope  is  of  hard  rubber,  the  flexible  portion  being  of  wire  over- 
laid with  soft  rubber  and  covered  with  silk  webbing.  The  ear  tubes  are 
separable,  each  connecting  with  the  flexible  portion  by  means  of  a  bayonet 


Figure  59.    The  "Laennec"  Stethoscope. 

joint.  A  heavy  spring,  somewhat  similar  to  the  pattern  of  Knight,  to- 
gether with  a  toggle  joint,  maintains  an  even  and  well-regulated  pressure 
upon  the  ear.  The  instrument  is  provided  with  three  tips,  the  same  as  in 
the  pattern  of  Camman  before  described. 

Denison's  Stethoscope  is  a  modification  and  improvement  of  the  Laennec 
pattern.     As  evidenced  by  figure  60,  the  principal  feature  of  this  stethoscope 
rj    3  f)  3  J  J (- 


EXAMINATIONS    OF    CHEST    AND    LUNGS.  53 

is  the  conical  shape  of  the  tubes  which  present  a  gradually  decreasing 
diameter,  from  the  pectoral  ending  to  the  ear  tip.  The  forked  piece  is 
large,  as  are  the  elastic  parts  that  connect  it  with  the  ear  tubes.  These 
elastic  sections  are  of  rubber,  also  conical  in  form,  and  contain  the  coiled 
sound-transmitting  wire  in  their  substance.  The  spring  and  controlling 
screw  are  like  those  of  the  Laennec  before  described.  The  fork  of  this  in- 
strument terminates  in  a  bell  form  about  one  inch  in  diameter.  This  is 
used  in  making  examinations  of  the  heart.  An  ordinary  chest-piece  about 
i^4  inches  in  diameter  is  so  shaped  as  to  slip  or  telescope  within  this  tip. 
As  the  arms  and  joints  are  of  hard  rubber,  much  of  the  perversion  of  natu- 
ral sounds  and  elevation  of  pitch,  common  to  instruments  where  metal 
tubes  are  used,  are  avoided.  The  instrument,  by  its  construction,  possesses 
the  power  of  concentrating  as  well  as  transmitting  the  waves  of  sound.  In 
addition  to  the  three  tips,  common  to  the  stethoscopes  previously  described, 
it  is  provided  with  a  bell  three  inches  in  diameter.  The  purpose  of  this 
large  bell  is  to  secure  the  advantages  of  stethoscopic  percussion.  This  is 
intended  to  be  held  by  the  patient  about  one  inch  in  front  of  the  open 
mouth,  while  the  examiner  makes  forcible  percussion  (chiefly  during  expi- 
ration) with  a  view  to  obtaining  in  certain  cases  the  "cracked  metal"  and 
hollow  sounds  diagnostic  of  bronchial  dilatation  and  cavities  connecting 
with  the  bronchial  tract.  It  is  said  to  be  of  great  assistance  in  mapping 
out  these  conditions. 


Figure  60.    Denison's  Stethoscope. 

Denison,  the  originator  of  these  improvements,  suggests  the  following 
test  for  utility  and  sound-transmitting  power  of  a  stethoscope:  Interpose 
the  left  hand  between  a  watch  and  the  medium-sized  bell  of  the  instrument, 
the  watch  resting  upon  the  middle  of  a  table  or  glass  show-case.  Press  the 
bell  of  the  stethoscope  against  the  palm  or  back  of  the  hand  firmly  and 
thus  listen  to  the  ticking  of  the  watch.  That  instrument  is  the  best  which 
most  clearly  and  distinctly  transmits  the  sounds  of  the  interior  workings  of 
the  watch.  It  is  claimed  that  by  this  test  the  inferiority  of  other  cheaply 
constructed  instruments,  together  with  the  phonendoscope,  auscultoscope, 
etc.,  is  plainly  demonstrated. 

Paul's  Stethoscope  is  constructed  with  a  circular  air  chamber  outside  of 
the  chest-piece,  the  cavity  connecting  by  means  of  a  rubber  hose  with  an 
exhaust  bulb,  by  means  of  which  an  air  vacuum  may  be  produced.  It  is 
claimed  that  sufficient  suction  may  be  secured  in  this  manner  to  hold  the 
chest-piece  in  contact  with  the  skin,  thus  releasing  both  hands  of  the  oper- 
ator. As  exhibited  in  figure  61,  the  forked  piece  in  this  instrument  termi- 
nates in  elastic  tubes  of  heavy  rubber.  These  connect  directly  with  the  ear 
and  terminate  in  small  hard  rubber  ear  tips. 


54 


MECHANICAL    AIDS    IN    DIAGNOSIS. 


Corwin's  Compound  Stethoscope  consists  of  two,  three  or  more  stetho- 
scopes, all  of  the  Camman  pattern,  connecting  with  a  single  fork  and  chest- 
piece.  They  are  especially  adapted  for  teacher  and  student  because  the 


Figure  61.    Paul's  Stethoscope. 


same  sounds  may  be  conducted  to  all  at  the  same  time,  thus  enabling  the 
instructor  to  convey  to  the  students  accurate  information  regarding  the  Char- 


Figure  62.    Corwin's  Compound  Stethoscope. 

acter  of  the  sounds  emitted.  By  increasing  the  number  of  instruments 
several  students  may  listen  and  receive  instructions  at  the  same  time.  The 
method  of  attaching  the  various  stethoscopes  is  shown  by  figure  62. 

P  honendoscope. 

This  instrument  consists  of  a  heavy  metallic  cup  with  low  margins,  in 
which  a  light  elastic  hard  rubber  diaphragm  is  caused  to  vibrate  both  by 
the  sound  waves  and  body  movements.  The  instrument  is  constructed 
somewhat  on  the  telephone  principle.  It  is  applicable  to  the  examination 
of  other  than  respiratory  organs.  It  has  been  claimed  that  with  this  instru- 
ment it  is  possible  to  hear  many  of  the  sounds  emitted  by  various  organs, 
while  performing  their  natural  functions,  sounds  that  cannot  be  heard 
through  other  forms  of  mechanical  appliances.  Subsequent  investigations 
by  leading  specialists,  however,  fail  to  attribute  any  advantages  to  this  in- 
strument not  found  in  the  better  patterns  of  stethoscopes. 

The  phonendoscope  comprises  a  heavy  metallic  base,  on  one  side  of 
which  a  shallow  cup  is  formed,  the  latter  being  covered  with  a  thin  hard 
rubber  disc.  External  to  this  disc  a  second  and  similar  hard  rubber  plate 
forms  the  outer  surface  of  the  instrument.  To  the  center  of  the  latter 
plate  a  rod,  about  two  inches  in  length,  is  attached,  which  terminates  in  a 
small  hard  rubber  disc-shaped  head.  To  the  back  of  the  instrument  and 


EXAMINATIONS    OF    CHEST    AND    LUNGS. 


55 


connecting  with  the  chamber  formed  between  the  metal  portion  and  the 
inner  of  the  two  discs  referred  to,  two  rubber  tubes,  about  eighteen  inches 
in  length,  are  attached,  each  terminating  in  small  ear-pieces  adapted  for 


Figure  63.    Phonendoscope. 


fitting  into  and  remaining  within  the  auditory  canal.  By  placing  the  small 
rod  over  the  part  to  be  examined,  sounds  that  would  otherwise  escape 
detection,  may  be  heard.  The  instrument  is  more  sensitive  when  only  the 
inner  diaphragm  is  used,  and  when  this  is  desired,  the  external  one  may  be 
removed,  as  it  is  attached  by  a  bayonet  catch.  As  shown  by  figure  63  it  is 
claimed  that  the  instrument  is  for  many  purposes  superior  to  the  stethoscope. 
It  is,  however,  we  believe,  less  definite  and  accurate  than  a  perfect  binau- 
ral  stethoscope,  as  it  does  not  properly  differentiate  the  sounds  transmitted. 
They  come  muffled  to  the  ear,  about  the  same  as  when  the  whole  side  of 
the  head  is  pressed  against  the  chest  wall. 

Percussion. 

Percussion  is  often  employed  in  chest  examinations,  the  character  of  the 
sound  emitted  determining  the  condition  of  the  part  under  examination. 
Direct  or  immediate  percussion,  where  the  blow  is  struck  directly  on  the 
skin,  is  seldom  employed.  Usually  mediate  percussion,  where  the  blow 
is  directed  against  some  intervening  substance,  such  as  the  finger  of  the 
examiner,  or  a  special  instrument  called  a  pleximeter  is  preferred. 

Percussion  in  which  instruments  are  employed  is  mediate  and  may  be 
either  simple  or  auscultatory.  The  instruments  for  simple,  mediate  per- 
cussion are  hammers  and  pleximeters. 

Percussion  Hammers. 

Percussion  hammers  consist  of  small  mallets,  usually  with  elastic  heads 
or  faces.  They  are  employed  for  producing  percussion  upon  the  part  under 
examination,  such  as  the  chest  or  other  portion  of  the  thorax.  There  are 
two  general  forms,  one  having  a  head  made  of  soft  rubber,  the  other  a  head 


Figure  64.    Flint's  Percussion  Hammer. 


of  metal  or  other  firm  material  with  a  soft  rubber  face  or  striking  surface. 
Hammers  with  heads  of  soft  rubber  are  generally  preferred,  those  com- 
posed largely  of  metal  being  so  heavy  as  often  to  cause  pain  by  the  force 
of  the  blow. 


56 


MECHANICAL    AIDS     IN     DIAGNOSIS. 


Flint's  Percussion  Hammer  usually  consists  of  a  cylindrical  soft  rubber 
head  2  to  2^  inches  in  length  by  about  y2  inch  in  diameter.  The  shank 
and  handle  may  be  of  hard  rubber  or  metal.  If  of  the  latter,  care  should 
be  exercised  in  the  construction  that  the  instrument  be  not  too  heavy.  It 
is  illustrated  by  figure  64. 


Figure  65.    Taylor's  Percussion  Hammer 


Taylor's  Percussion  Hammer,  as  shown  by  figure  65,  consists  of  an  arrow- 
shaped  head  about  2%  inches  in  long  diameter  by  i^  inches  in  breadth  at 
its  base.  The  edges  are  beveled,  the  head  passing  through  the  loop  of  a 
metallic  shank  with  handle.  The  instrument  is  one  of  the  heavier  patterns, 
and  is  about  eight  inches  in  length. 


Figure  66.    Neihoffer's  Percussion  Hammer. 


Neihoffer's  Percussion  Hammer  consists  of  a  metallic  head  terminating  in 
a  hemispherical  soft  rubber  face.  As  exhibited  by  figure  66,  the  handle  is 
light  and  somewhat  elastic.  While  the  instrument  is  neat  in  appearance, 
it  is  not  generally  considered  to  possess  any  advantage  over  the  cheaper 
pattern  of  Flint. 

Pleximeters. 

Pleximeters  consist  of  instruments  used  to  receive  the  blow  of  the  per- 
cussion hammer,  forming  a  sort  of  cushion  between  the  latter  and  the  chest 
wall.  They  are  manufactured  in  divers  shapes  and  from  many  kinds  of 
material,  hard  rubber,  soft  rubber,  metal,  ivory,  wood,  bone,  glass  and  cel- 
luloid being  employed.  One  or  two  varieties  are  graduated  in  inches  and 
centimeters  that  they  may  be  used  in  measurements.  All  should  be  nar- 
row enough  to  rest  in  the  spaces  between  the  ribs  of  an  adult. 


Figun 


.    Plain  Hard  Rubber 
Pleximeter. 


Figure  68.    Glass  Pleximeter. 


Figure  69.     Struck's 
Pleximeter. 


A  Plain  Pleximeter  usually  consists  of  an  oval  plate  with  projections,  or 
ears  extending  upward,  thus  affording  a  good  grasp  for  the  instrument. 
Those  in  most  common  use  are  about  two  inches  in  length  by  one  inch  in 
breadth  and  manufactured  from  hard  rubber.  They  are  outlined  by  figure  67. 

The  Glass  Pleximeter,  depicted  by  figure  68,  does  not  differ  materially  in 
shape  from  the  plain  hard  rubber  pattern  before  described.  Generally 
they  are  graduated  in  centimeters  that  they  may  be  used  for  measure- 
ments. 


DETERMINING  BODY  TEMPERATURE. 


57 


Struck's  Pleximeter  consists  of  a  small  spool-shaped  instrument  manu- 
factured from  hard  rubber.  As  illustrated  by  figure  69,  the  small  face  is 
about  5-8  inch,  while  the  larger  is  about  ^  inch  in  diameter. 

Sansom's  Pleximeter,  as  shown  by  figure  70,  consists  of  a  thin,  flat,  ob- 
long plate  of  vulcanite  an  inch  long  by  half  an  inch  wide,  having  on  its 
upper  surface  a  slender  vertical  column  an  inch  and  a  half  in  height, 
surmounted  by  a  smaller  plate  ^  by  y%  of  an  inch,  set  parallel  to  the  former 
plate.  It  is  so  constructed  that  the  vibrations  are  communicated  to  the 
fingers,  thus  enabling  the  examiner  to  form  estimates  in  terms  of  vibra- 
tion as  well  as  of  sound. 


Figure  70.    Sansom's  Pleximeter. 


Figure  71.    Camman's  Percussion  Stethoscope. 


Auscultatory  Percussion  requires  the  use  of  some  form  of  percussion 
instrument  in  connection  with  a  stethoscope. 

Camman's  Percussion  Stethoscope  consists  of  a  solid  cylinder  of  wood,  at 
one  end  forming  a  truncated  wedge,  at  the  other  enlarged  into  a  disc- 
shaped  ear-piece.  The  wedge  form  is  adapted  for  use  in  the  intercostal 
spaces.  Percussion  is  made  by  an  assistant  in  any  manner  desired.  It  is 
outlined  by  figure  71. 


Figure  72.    Ingals'  Emballometer. 

Ingals'  Emballometer,  as  illustrated  by  figure  72,  consists  of  a  soft  rub- 
ber bulb,  rubber  tubing  and  a  cylinder  and  plunger,  the  latter  arranged  to 
work  with  air  pressure  produced  by  the  bulb.  The  percussion  end  is  covered 
with  a  soft  rubber  disc  and  receives  the  blow  of  the  plunger.  Pressure  of 
the  bulb  drives  the  plunger  forward,  giving  a  blow  in  proportion  to  the 
suddenness  of  the  bulb  contraction.  On  releasing  the  bulb,  the  plunger 
returns  to  place  as  the  latter  fills  with  air.  This  can  be  used  with  a  stetho- 
scope and  without  an  assistant. 

Ingals  advises  that  the  stethoscope  be  held  with  the  left  hand,  the  bulb  by 
the  last  two  fingers  of  the  right  hand,  and  the  cylinder  with  the  thumb  and 
forefinger  of  the  same  hand.  The  instrument  may  thus  be  moved  about 
as  desired.  Small  chest-pieces  should  be  used  on  the  stethoscope  when 
used  in  connection  with  this  instrument. 


DETERMINING  BODY  TEMPERATURE. 

Instruments  for  ascertaining  the  body  temperature  are  called  clinical 
thermometers. 

The  thermometerconsists  of  a  graduated  glass  capillary  tube  closed  at  both 
ends,  the  lower  portion  of  the  bore  being  enlarged  into  a  bulb,  or  reservoir. 


58  MECHANICAL    AIDS     IN     DIAGNOSIS. 

The  bulb  is  filled  with  mercury  by  means  of  submerging  the  yet  open  end 
of  the  tube  while  the  bulb,  newly  blown,  is  only  partially  cooled.  Into  the 
semi-vacuum  thus  created  the  mercury  rises  by  atmospheric  pressure,  the 
bulb  becoming  partially  filled.  This  mercury,  being  afterward  violently 
boiled,  provides  the  means  by  which  the  complete  filling  is  accomplished, 
the  bulb  quickly  filling  owing  to  the  higher  vacuum  thus  obtained.  The 
residue  of  air — a  mere  bubble  in  the  bulb — is  withdrawn  through  the  mer- 
cury in  the  base  by  tapping. 

Subsequently  the  thermometer  is  tried  and  adjusted;  that  is  to  say,  the 
necessary  size  of  each  individual  bulb  (relative  to  its  bore)  must  be  found 
by  actual  experiment,  as  must  also  the  quantity  of  mercury  to  be  left 
therein.  This  is  determined  by  heating  the  thermometer  in  water  to  the 
highest  temperature  that  it  will  be  required  to  indicate,  such  "warming 
out"  expelling  all  superfluous  mercury  through  the  open  top  of  the  tube. 
In  this  manner  any  desired  scale  is  obtained;  the  proportion  between  bulb 
and  bore  dividing  the  number  of  degrees  that  will  be  embraced  within  the 
thermometer's  range,  and  the  adjusting  or  "warming  out"  process 
definitely  fixing  its  points  of  highest  and  lowest  temperature. 

Adjustment  completed,  the  tube  is  finally  "deprived"  of  all  air  (which 
otherwise  would  completely  fill  the  bore  in  the  space  above  the  mercury) 
by  means  of  "sealing  off"  the  top  of  the  tube  through  the  heated-up  mer- 
cury in  the  bore,  this  being  effected  by  means  of  a  finely  drawn  out  splint. 

Upon  the  mercury  receding  as  it  cools,  a  vacuum  (obviously  a  most 
essential  part  of  the  instrument)  remains  above  the  mercury.  As  the  latter 
expands  and  contracts  in  the  bulb  and  capillary  tube,  its  upper  surface  as 
indicated  on  the  scale  denotes  the  temperature  of  the  medium  surrounding 
the  bulb. 

In  the  manufacture  of  clinical  thermometers,  it  is  most  essential  that  they 
be  accurate,  self-registering  and  sensitive.  To  Hicks  of  London  we  are 
largely  indebted,  not  only  for  many  improvements  in  the  general  construc- 
tion of  these  instruments,  but  for  a  degree  of  accuracy  in  graduation  and  a 
general  quality  not  excelled,  if  equaled,  by  any  other  maker. 

Clinical  Thermometers  are  manufactured  with  three  different  scales; 
Fahrenheit,  Reaumur  and  Centigrade.  Fahrenheit  assumed  that  a  mixture 
of  snow  and  salt  represented  the  lowest  possible  temperature  and  adopted 
that  as  zero.  He  estimated  that  mercury  contracted  one  thirty-second  of 
its  volume  on  being  cooled  from  the  freezing  point  to  his  zero  mark,  and 
expanded  one  one-hundred  and  eightieth  on  being  heated  from  the  freez- 
ing to  the  boiling  point. 

The  scale  that  bears  his  name,  therefore,  is  represented  by  32°  at  freez- 
ing, to  which  is  added  180°  or  212°  at  boiling  point.  This  system  is  in  gen- 
eral use  in  England,  Holland  and  America.  The  Reaumur  scale,  used  in 
Germany  and  Russia,  fixes  zero  at  the  freezing  and  boiling  at  80°.  The 
Centigrade  system,  used  in  France,  also  fixes  the  zero  mark  at  freezing,  but 
takes  100°  as  the  point  of  boiling. 

As  the  Fahrenheit  scale,  like  the  English  catheter  scale,  is  purely 
arbitrary,  it  should  be  abandoned  for  one  in  which  zero  marks  the  freezing 
and  100°  or  1000°  the  point  of  boiling,  all  subdivisions  being  decimally 
fixed. 

Clinical  thermometers  present  a  limited  scale,  usually  ranging  from  95° 
to  no0  Fahrenheit,  or  35°  to  45°  Centigrade.  The  Fahrenheit  scale  may 
be  converted  into  the  Centigrade  by  subtracting  32  from  the  given  temper- 
ature and  multiplying  the  remainder  by  f.  The  Centigrade  may  be  con- 


DETERMINING  BODY  TEMPERATURE.  59 

verted  into  the  Fahrenheit  by  first  multiplying  the  given  temperature  by 
if  and  then  adding  32  to  the  product. 

The  scales  of  the  better  grades  of  thermometers  are  now  divided  by 
engine  work,  and  the  markings  plainly  etched  in  the  surface  of  the  tube. 

In  securing  correct  markings  and  subdivisions,  careful  comparison  with 
standard  instruments  is  essential.  Usually  the  highest  and  lowest  points 
of  registration  are  correctly  marked,  the  subdivisions  being  accurately 
graduated  by  mechanical  methods. 

Generally  speaking  it  would  be  disadvantageous  were  the  extremes  of  a 
thermometer's  range  to  be  selected  for  its  points,  though  this  statement 
applies  to  thermometers  having  a  considerable  range  rather  than  to  clinical 
thermometers.  Liability  to  error  over  the  entire  range  would  in  such  a 
case  be  unnecessarily  increased.  But  over  and  above  this,  the  temperature 
best  chosen  for  exact  determination  by  comparison  with  the  standard,  is 
that  at  about  the  regions  of  greatest  general  utility. 

As  a  matter  of  fact,  however,  all  clinical  thermometers  with  any  preten- 
sions to  being  first-class  instruments  should  be  and  are  pointed  at  three 
temperatures,  usually  at  95°,  100°  and  105°,  or  at  95°,  100°  and  110°. 
Thermometers  of  greater  range  are  given  more  numerous  points,  of  course, 
in  proportion  to  their  lengths  of  scale.  Were  two  points  only  given  them 
(as  is  doubtless  the  case  with  cheap  thermometers),  serious  errors,  owing 
to  inequality  or  tapering  of  the  bore,  minute  flints  and  air  bubbles  in  the 
glass,  might  occur,  a  mathematically  true  bore  being  an  impossibility. 


Figure  73.    Fever  Thermometer,  Showing  Fahrenheit  and  Centigrade  Scales. 

Modern  clinical  thermometers  differ  from  those  generally  used  for  ascer- 
taining the  weather  temperature  in  being  self-registering.  Instruments 
that  are  not  so  constructed,  necessitate  the  noting  of  the  temperature  before 
they  are  removed  from  the  mouth,  axilla  or  other  selected  location.  This 
is  awkward  and  sometimes  misleading  and  as  a  consequence  nearly  all 
thermometers  for  clinical  purposes  are  supplied  with  some  form  of  a  detach- 
ing index.  These  instruments  are  made  self-registering,  either  by  separat- 
ing a  small  portion  of  the  mercury  in  the  capillary  tube  and  introducing 
between  it  and  the  main  column  a  small  quantity  of  air,  or  as  is  now  the 
universally  adopted  method,  by  providing  a  cut-off  point  in  the  lower  por- 
tion of  the  tube,  the  entire  column  of  mercury  being  left  as  an  index  after 
the  withdrawal  of  the  thermometer.  This  cut-off  may  be  of  any  form  so 
long  as  the  passage  of  the  mercury  column  requires  a  stronger  force  than 
specific  gravity  to  pass  the  obstruction.  In  either  of  these  methods  the 
detached  portion  does  not  recede  with  the  column,  but  remains  stationary 
at  the  highest  point  reached  by  the  expansion  of  the  contained  mercury. 
The  latter  method  of  manufacture  has  now  entirely  superseded  the  former, 
and  avoids  any  possibility  of  the  index  being  lost  by  joining  the  main 
column  of  mercury  as  was  so  often  the  case  with  indexes  of  the  old  air- 
speck  form. 

Self-Registering  Clinical  Thermometers  are  now  used  to  the  exclusion  of 
all  non-registering  patterns.  One  of  the  many  devices  employed  for  sepa- 
rating the  mercury  column  is  shown  by  figure  74.  Many  others  equally  as 
good  have  been  placed  on  the  market  by  domestic  and  foreign  makers. 

The  forcing  down  of  the  registering  index  may  be  accomplished  by 
sharply  swinging  the  instrument  from  front  to  rear  while  firmly  holding 


60  MECHANICAL    AIDS    IN     DIAGNOSIS. 

it  lengthwise  between  the  thumb  and  first  and  second  fingers  with  the 
bulb  downward.  This  swinging  motion  will  be  found  more  effective  if 
suddenly  arrested,  but  in  such  cases  there  is  a  liability  to  split  the  thermom- 
eter in  the  neck  or  that  portion  immediately  above  the  bulb.  This  is 
because  the  bore,  being  flat,  is  liable  to  split  at  its  two  knife-edge  limits. 
In  such  cases  the  mercury  clings,  and  the  instrument  becomes  altogether 
useless,  because  a  small  split  will  spread  with  every  slight  jar.  Efforts  to 
suddenly  arrest  the  force  should  not  suggest  to  the  uninitiated  the  advis- 
ability of  striking  something  with  the  thermometer,  a  method  that,  like 
striking  the  palm  of  the  hand,  is  occasionally  attempted  in  ignorance. 


Figure  74.    Self-Registering  Clinical  Thermometer. 

Owing  to  defective  eye  sight,  poor  light,  or  an  exceedingly  fine  bore  in 
a  thermometer,  the  index  can  often  be  read  only  with  difficulty.  To 
obviate  this,  instruments  are  maufactured  with  a  magnifying  index. 

The  Magnifying  Index  Clinical  Thermometer,  as  shown  by  figure  75,  is  con- 
structed with  the  front  of  the  tube  in  a  prismatic  or  lens  form.  Usually 
this  results  in  enlarging  the  column  of  mercury  from  five  to  ten  times, 
thus,  rendering  it  easy  to  read.  This  form,  originally  manufactured  by 
Hicks,  is  now  generally  adopted  by  all  makers. 

Clinical  thermometers  should  be  selected  that  are  not  only  provided  with 
a  correct  scale  but  that  have  been  well  seasoned  before  being  marked. 
It  is  well  established  that  certain  changes  are  likely  to  take  place  in 
instruments  of  this  class  due  to  a  constant  gradual  shrinkage,  which  under 
ordinary  conditions  follows  the  manufacture  of  a  thermometer  tube.  This 
is  so  noticeable  that  if  a  thermometer  were  marked  and  divided  immedi- 
ately after  being  filled,  it  would  soon  show  an  inaccuracy  amounting  in 


Figure  75.    Magnifying  Index  Clinical  Thermometers. 

some  cases  to  a  seeming  rise  in  temperature  of  a  degree  or  more.  The 
greater  part  of  this  contraction  of  the  bulb  takes  place  during  the  first  six 
months  after  the  manufacture.  This  danger  may  be  avoided  by  the  use  of 
tubes  well  seasoned  by  months  or  years  of  storage  before  marking,  or  by 
certain  annealing  processes  by  which  comparatively  unchangeable  tubes 
are  produced  in  a  few  days. 

As  accuracy  is  at  all  times  essential,  it  is  necessary  that  clinical  ther- 
mometers be  occasionally  tested  with  standard  instruments,  in  order  that 
their  variations,  if  any,  be  known.  This  may  be  secured  by  sending  such 
instruments  to  certain  universities,  standard  makers,  or  to  large  dealers, 
prepared  to  make  or  secure  comparative  tests. 

Many  instruments  are  re-tested  by  makers  and  dealers  before  being 
offered  for  sale.  In  this  process  each  thermometer  is  compared  with  a 
standard  instrument  and  its  relative  readings  recorded  on  a  blank  prepared 
for  the  purpose,  on  which  is  also  noted  the  make  and  serial  number  of  the 
thermometer.  These  records  are  called  certificates,  and  the  instruments 
that  include  them  are  sold  at  a  slightly  advanced  price. 


DETERMINING  BODY  TEMPERATURE.  61 

It  is  an  advantage  to  have  an  instrument  that  is  delicately  sensitive, 
that  time  be  not  unnecessarily  wasted  in  securing  a  proper  temperature 
record.  An  instrument  that  will  register  the  maximum  degree  of  heat  in 
one  minute  is  preferable  to  one  requiring  five  minutes.  It  is  essential, 
however,  that  physicians  should  know  the  shortest  time  required  for  each 
thermometer  they  employ  to  reach  such  temperature.  For  instance,  if  this 
be  two  minutes,  it  is  evident  that  the  retention  of  the  instrument  in  posi- 
tion for  i  y^  minutes  would  not  secure  a  correct  record.  On  the  other  hand, 
valuable  time  would  be  wasted  by  keeping  the  instrument  in  place  longer 
than  two  minutes. 

The  time  required  for  a  thermometer  to  reach  its  maximum  temperature 
must  depend  on  the  shape  of  the  bulb,  the  quantity  of  mercury  it  contains 
and  the  thickness  of  the  glass  forming  its  walls.  It  is  quite  evident  that 
the  greater  the  amount  of  surface  exposed  to  a  given  quantity  of  mercury, 
the  quicker  it  will  absorb  heat  from  the  surrounding  medium.  Many  plans 
for  increasing  the  absorbing  surface  of  thermometer  bulbs  have  been 
devised.  Among  these  are  slender,  divided  and  flat  bulbs. 

The  less  the  quantity  of  mercury  contained  in  a  thermometer  the 
quicker  it  will  reach  a  maximum  temperature.  This  also  applies  to  the 
thickness  of  the  glass  surrounding  the  mercury.  If  it  be  quite  thin,  a 
uniform  heat  throughout  the  bulb  will  be  quickly  obtained.  It  is  evident 


Figure  76.     Plain  Quick-Registering  Clinical  Thermometer. 

then  that  the  smaller  the  bulb,  the  thinner  the  glass  and  the  more  surface 
exposed,  the  quicker  will  the  instrument  register  the  highest  possible 
temperature.  These  principles,  however,  can  be  carried  to  excess.  The 
so-called  one-minute  thermometers  are  usually  quite  frail.  Thermometers 
have  been  made  that  will  reach  a  maximum  temperature  in  thirty  seconds, 
but  as  a  rule  they  are  too  easily  broken  to  be  serviceable. 

The  Quick-Registering  Clinical  Thermometer,  outlined  by  figure  76,  exhib- 
its one  of  the  frail  varieties,  which,  though  it  will  ordinarily  register  a  max- 
imum temperature  in  about  one  minute,  is  too  fragile  to  prove  a  profitable 
investment. 

Hicks'  Link  Bulb  Thermometer,  as  portrayed  by  figure  77,  represents  one 
of  the  forms  of  divided  bulbs  employed  to  secure  a  rapid  registration. 
The  reservoir  is  forked,  the  outer  ends  being  united  by  a  solid  section  so 
that  the  whole  is  in  link  form.  This  supplies  a  large  absorbing  surface  so 
that  the  bulb  and  contained  mercury  quickly  acquire  the  same  temperature 
as  the  surrounding  medium. 

While  this  instrument  will  reach  a  maximum  temperature  in  one  minute 
or  less,  it  is  as  frail  as  it  is  sensitive,  and  being  of  expensive  construction 
has  commanded  only  a  limited  sale. 

Hicks'  Duplex  Clinical  Thermometer,  as  sketched  by  figure  78,  exhibits  one 
of  the  most  durable  and  satisfactory  forms  of  the  quick-registering  instru- 
ments. Like  the  one  previously  shown,  the  mercury  occupies  a  divided 
bulb,  but  in  this  case  the  two  slender  sections  are  joined  by  a  flat  section  of 
glass,  thus  adding  greater  strength  to  the  thermometer,  without  sacrific- 
ing its  quick-registering  powers.  This  instrument  will  reach  a  maximum 
temperature  in  less  than  one  minute,  and  is  usually  constructed  with  a 
magnifying  index. 


62  .MECHANICAL    AIDS     IN     DIAGNOSIS. 

We  would  suggest  that  upon  receiving  a  thermometer,  it  be  tested  by 
immersion  in  water  at  about  the  normal  body  temperature,  say  for  five 
minutes.  After  shaking  down  the  mercury  it  should  be  tested  for  four 
minutes.  If  the  temperature  is  found  the  same  after  this  test,  it  should  be 
again  tested  for  three  minutes ;  if  this  reaches  the  same  result,  it  may  then 
be  tested  for  two  minutes,  and  so  on  until  a  test  is  made  in  which  the  max- 
imum temperature  is  not  reached. 


Figure  77.    Hicks'  Link  Bulb  Quick-Registering  Clinical  Thermometer. 

The  shortest  time,  then,  in  which  the  proper  temperature  is  secured, 
should  be  selected  for  each  registration,  and  if  accurately  timed  in  all  cases, 
the  physician  will  be  certain  to  secure  perfect  results.  During  this  test, 
the  water  should  be  maintained  at  an  even  temperature  by  means  of  a 
non-registering  clinical  thermometer.  In  making  the  above  series  of  tests, 
the  bulb  of  the  thermometer  should  be  cooled  to  about  the  same  temper- 
ature as  before  the  first  test  was  attempted.  It  should,  moreover,  be  borne 
in  mind  that  the  colum  of  mercury  in  a  clinical  thermometer  will  require  a 
longer  time  to  settle  in  cold  than  in  warm  weather. 

Ordinarily  the  bulb  of  a  thermometer  is  inserted  in  the  mouth  beneath 
the  tongue,  while  the  lips  are  closed  around  the  stem  of  the  instrument. 
Hot  or  cold  substances  should  never  be  taken  in  the  mouth  for  at  least 
thirty  minutes  before  the  introduction  of  the  thermometer,  as  otherwise 


Figure  78.    Hicks'  Duplex  Quick-Registering  Clinical  Thermometer. 

a  correct  temperature  may  not  be  obtained.      The  temperature  may,  how- 
ever, be  taken  in  the  axilla,  rectum  or  vagina. 

Good  thermometers  can  be  obtained  that  are  strong  enough  to  be 
serviceable,  accurate  in  marking,  moderate  in  price,  and  that  will  register 
a  maximum  temperature  in  from  one  and  one-half  to  two  minutes.  Such 
an  instrument  would  seem  to  be  ideal. 


Figure  79.    Author's  Ideal  Pattern  Clinical  Thermometer. 

The  Author's  Ideal  Pattern  Clinical  Thermometer,  as  shown  by  figure  79, 
is  self-registering,  with  magnifying  index,  a  safe  cut-off,  yet  one  that  allows 
the  column  of  mercury  to  be  easily  forced  through  it,  a  coloring  in  the 
scale  etchings  that  is  reasonably  permanent,  a  bulb  small,  rather  short, 
somewhat  slender  and  registering  just  inside  of  the  two-minute  mark.  As 
a  matter  of  convenience  to  physicians,  we  would  recommend  that  manu- 
facturers not  only  furnish  with  each  thermometer  a  certificate  of  the  varia- 
tions from  the  mark  scale,  but  the  time  required  for  each  instrument  to 
reach  its  maximum  temperature.  Such  a  thermometer  would  appear  to 
meet  every  necessary  indication,  and  can  be  furnished  at  a  reasonable  price. 

Hicks'  Aseptible  Clinical  Thermometer,  called  by  him  "The  Climax,"  is 
shown  by  figure  80.  It  is  a  well-known  fact  that  the  figures  and  lines  form- 
ing the  scales  of  many  thermometers  lose  their  coloring  matter,  thus 
becoming  more  or  less  indistinct.  Further  than  this,  the  creases  formed 


STUDYING    CONDITION    OF    PULSE. 


63 


by  the  cutting  of  the  scale  and  figures  form  receptacles  for  conveying 
disease  germs.  The  above  instrument  devised  by  Hicks,  furnishes  a  scale 
of  graduations  and  figures  of  an  absolutely  permanent  character  within  a 
thermometer  that  presents  a  perfectly  smooth  face  in  its  entire  circumfer- 
ence. The  scale  being  backed  with  white  opal  glass  renders  the  readings 
very  clear  and  distinct.  By  holding  the  thermometer  between  the  eye  and 
the  light,  the  index  may  be  easily  read,  either  by  natural  or  artificial  light. 


Figure 


Hicks'  Aseptible  Clinical  Thermometer. 


Clinical  thermometers  are  usually  straight  and  about  4  inches  in  length. 
A  curved  variety,  one  with  the  stem  bent  sharply  upon  itself  in  order  to 
shorten  the  instrument  to  about  3  inches  was  formerly  quite  popular,  but 
owing  to  the  difficulty  in  cleansing,  it  is  now  but  little  used. 


Figure  81.     Horizontal  Bulb  Surface  Thermometer. 

A  second  class  of  instruments  sometimes  used  are  called  surface 
thermometers. 

Surface  Thermometers  are  constructed  with  bulbs  that  present  an 
enlarged  or  flattened  surface.  They  are  used  for  ascertaining  the 
surface  temperature  in  various  portions  of  the  body.  They  are  graduated 
lower  in  scale  and  with  a  longer  range  than  ordinary  fever  thermometers. 
Generally  they  are  used  upon  opposite  sides  of  the  body,  two  at  the 
same  time,  for  purposes  of  comparative  diagnosis. 


Figure  82.     Vertical  Bulb  Surface  Thermometer. 


The  two  surface  thermometers  exhibited  by  figures  81  and  82  differ  only 
in  the  plane  of  the  bulb  enlargement.  The  first  is  constructed  with  the 
bulb  surface  at  right  angles  to  the  stem,  while  the  second  pattern  is  pro- 
vided with  a  bulb  which,  although  enlarged,  rests  in  the  same  plane  with 
the  mercury  column. 


STUDYING  CONDITION  OF  PULSE. 

The  arterial  pulse  movements  may  be  automatically  recorded  on  an 
enlarged  scale  by  an  instrument  called  a  sphygmograph.  The  essential 
features  are  facility  of  application  and  accuracy  of  results.  The  tracing  is 
called  a  sphygmogram  and  shows  the  rate,  degree  of  regularity  and  equality 
of  the  heart  beats;  the  mode  of  contraction  of  the  ventricle,  condition  of 
capillary  circulation,  state  of  the  arteries  and  their  coats  and  some  of  the 
valvular  diseases  of  the  heart. 

The  material  upon  which  these  tracings  are  recorded  may  be  of  paper  or 
mica  smoked  over  a  lamp  or  candle  or  by  burning  camphor.  If  it  is 
desired  to  preserve  them  after  the  tracing  has  been  made,  they  may  be 
dipped  in  an  alcoholic  solution  of  shellac  or  benzoin. 


64 


MECHANICAL    AIDS     IN     DIAGNOSIS. 


As  results,  even  with  perfect  instruments,  depend  on  accurate  adjust- 
ment, great  care  must  be  exercised  in  locating  the  instrument  and  securing 
the  proper  amount  of  pressure. 


Figure  83.    Dudgeon's  Sphygmograph. 

Dudgeon's  Sphygmograph,  as  depicted  in  figure  83,  is  generally  consid- 
ered the  best  instrument  of  this  class.  It  is  a  little  less  complicated  than 
most  other  patterns  and  is  not  so  expensive.  It  combines  facility  of  appli- 
cation with  accuracy  of  results.  It  consists  of  a  metal  plate  held  against 
the  artery  by  a  slight  elastic  spring,  the  whole  securely  attached  to  the 
wrist  by  a  firm  elastic  band.  This  plate  moved  by  the  pulse  beat  causes  a 
system  of  levers  to  move  backward  and  forward.  The  levers  terminate  in  a 
pointed  marker,  which  rests  against  a  strip  of  smoked  paper  that  is  caused 
to  pass  through  the  machine  by  means  of  a  roller  operated  by  clockwork  in 
such  a  manner  that  it  travels  at  a  uniform  rate  of  speed. 


Figure  84.    Marey's  Sphygmograph. 

The  advantages  claimed  for  this  instrument  are  that  it  magnifies 
arterial  movements  50  times,  that  they  are  uniform,  that  the  pressure  of 
the  spring  may  be  regulated  from  one  to  five  ounces,  that  it  may  be  used 
with  equal  facility  no  matter  what  the  position  of  the  patient,  that  a  tracing 
of  the  pulse  may  be  quickly  made,  and  that  it  is  small,  easily  repaired  and 
sold  at  a  low  price. 

Marey's  Sphygmograph,  as  delineated  in  figure  84,  does  not  differ  mate- 
rially from  the  one  before  described  excepting  that  the  paper  travels  in  a 
different  direction.  It  consists  of  a  metal  frame  arranged  to  rest  closely 
on  the  forearm  to  which  it  is  attached  by  tapes.  An  ivory  button  resting 


STUDYING    CONDITION    OF    PULSE. 


65 


on  the  artery  to  be  examined  is  attached  to  a  delicate  flexible  spring  in 
such  a  manner  that  each  'pulsation  raising  the  button  causes  a  system  of 
attached  levers  to  act  in  a  corresponding  direction,  registering  their  move- 
ments on  a  strip  of  smoked  paper  or  other  material.  The  arrangement  of 
this  machine  is  such  that  the  strip  of  paper  will  pass  across  the  registering 
field  in  about  10  seconds. 


Figure  85.    Hill's  Sphygmometer. 

Hill's  Sphygmometer,  as  expressed  in  figure  85,  presents  an  accurate 
form  of  arterial  pressure  gauge.  It  comprises  a  flexible  steel  band,  encir- 
cling the  limb  and  provided  on  its  inner  or  contact  surface  with  a  thin,  soft 
rubber  bag.  This  bag  is  connected  with  a  small  compressing  air  pump, 
fitted  with  a  valve  and  pressure  gauge.  The  latter  consists  of  a  metallic 
tambour,  the  expansion  of  which  is  exhibited  in  a  highly  magnified  form  by  an 
index  and  pointer.  The  dial  is  graduated  in  millimeters  of  mercury.  It 
may  be  attached  to  the  arm  just  above  the  elbow,  or  in  children,  to  the  thigh. 
By  forcing  air  into  the  rubber  bag  with  which  the  band  is  lined,  the  pulsa- 
tion will  be  indicated  by  the  marker  and  correct  readings  obtained.  The 
instrument  possesses  great  advantages  for  clinical  purposes  and  is  partic- 
ularly adapted  for  class  demonstrations. 


HILL&BARNARDS 
'SPHYGMOMETER? 


J. HICKS.  SOLE  MAKER. LONDON. 

PATENT. 


Figure  86.    Pocket  Sphygmometer. 

The  Pocket  Sphygmometer,  as  shown  in  figure  86,  consists  of  a  glass  tube 
in  thermometer  form,  one  end  of  which  terminates  in  a  metallic  bulb  with 
a  soft  rubber  face  and  the  other  in  a  stop-cock  or  valve  by  which  the  quan- 
tity of  air  contained  within  the  column  is  regulated.  The  bulb  and  a  part 
of  the  tube  are  filled  with  mercury,  as  is  a  fever  thermometer.  They 
differ,  however,  in  that  the  bulb  is  elastic.  Before  applying  the  instru- 
ment to  the  arm,  pressure  should  be  made  upon  the  bulb  while  the  valve 
is  open  until  the  mercury  rests  at  the  zero  mark.  After  this,  if  the  valve 
be  closed  and  the  bulb  firmly  pressed  against  the  pulse,  the  variation  in 


66 


MECHANICAL    AIDS     IN     DIAGNOSIS. 


arterial  pressure  may  be  noted.     A  metallic  clamp  is  sometimes  supplied 
with  the  instrument  by  which  an  even  pressure  on  the  arm  may  be  secured. 


LOCATION  OF  CRANIAL  FISSURES. 

Cerebral  operations  may  involve  the  locating  of  certain  topographical 
points,  necessitating  in  some  instances  the  use  of  instruments  for  denning 
the  location  of  the  fissure  of  Rolando.  Instruments  for  this  purpose  are 
usually  called  cyrtometers  or  fissure-meters.  Generally,  these  consist  of. 
some  form  of  band  caused  to  lie  parallel  with  the  longitudinal  fissure,  to 
which  is  attached  an  arm  projecting  at  an  angle  of  67°,  the  junction  of  the 
two  being  placed  directly  over  Thane's  point.  With  the  instrument  in  this 
position  the  line  of  the  fissure  can  easily  be  traced. 


Figure  87.    Horsley's  Cyrtometer.  Figure  88.    Wilson's  Cyrtometer. 

Horsley's  Cyrtometer,  as  portrayed  in  figure  87,  is  a  plain  band  of  thin 
elastic  metal  to  which  is  attached  in  "Y"  form,  a  graduated  arm  by  which 
measurements  in  inches  may  be  noted.  In  use  the  straight  band  is  placed 
upon  one  side  of  the  longitudinal  fissure,  the  point  or  crotch  of  the  instru- 
ment resting  in  Thane's  point.  The  angle  of  the  arms,  one  to  the  other, 
is  67°. 

Wilson's  Cyrtometer,  as  depicted  in  figure  88,  is  a  metallic  elastic  head 
band  in  "T"  form,  the  band  proper  encircling  the  head  on  Reid's  base 
line,  the  stem  passing  over  the  head  antero-posteriorly  to  the  occipital  pro- 
tuberance. This  stem  is  provided  with  a  sliding  arm  attached  at  the  usual 
angle. 

EXPLORATION  OF  TISSUE. 

Abnormal  growths  and  conditions  frequently  require  the  use  of  instru- 
ments for  explorative  purposes.  Those  used  for  the  abstraction  of  liquids 
are  called  exploring  needles  or  exploring  trocars,  in  addition  to  which 
hypodermic  syringes  are  frequently  employed.  For  the  examination  of 
muscular  and  similar  substances,  tissue  extractors  are  required. 

Exploring-  Needles. 

These  consist  of  long  needles  of  good  size  with  sharp  points  and  pro- 
vided with  a  longitudinal  groove  extending  the  full  length  of  the  needle. 


EXPLORATION    OF    TISSUE.  67 

They  may  be  introduced  into  tumors,  swellings,  etc. ,  with  a  view  of  remov- 
ing a  small  portion  of  the  fluid  contents  for  microscopical  examination. 


Figure  89.    Exploring  Needle. 

The  Exploring  Needle,  exhibited  in  figure  89,  consists  of  a  sharp  pointed, 
coarse  needle,  provided  with  a  longitudinal  groove  extending  throughout  its 
full  length.  Generally  it  is  attached  to  a  double-threaded  head,  by  which 
it  may  be  joined  to  a  tube,  the  latter  serving  either  as  a  handle  or  as  a 
guard  for  the  protection  of  the  needle  when  not  in  use. 

Exploring-  Trocars. 

Exploring  trocars  differ  from  those  employed  in  paracentesis  in  being 
of  small  size  and  delicate  construction. 


Figure  90.    Exploring  Trocar. 

The  Exploring  Trocar,  as  shown  by  figure  90,  consists  of  a  minute  trocar 
and  canula  employed  in  cases  where  a  longer  instrument  than  a  needle 
is  required,  or  where  larger  quantities  of  suspected  fluid  are  desired  for 
examination.  The  better  patterns  are  made  with  a  silver  canula  and  sup- 
plied with  a  cap  for  protecting  the  point  when  not  in  use. 

Tissue  Extractors. 

These  consist  of  needles  or  trocar  pointed  instruments  provided  with 
some  form  of  barb  by  means  of  which  small  portions  of  the  soft  tissues 
may  be  extracted  for  microscopical  examination.  They  are  used  in  secur- 
ing specimens  from  tumors,  morbid  deposits,  muscular  tissues,  etc. 


Figure  91.    Duchesne's  Tissue  Extractor. 


Duchesne's  Tissue  Extractor,  as  portrayed  by  figure  91,  while  applicable 
to  various  conditions,  is  usually  employed  to  determine  whether  or  not  a 
muscle  has  undergone  fatty  degeneration.  In  suspected  cases  the  muscle 
is  examined,  as  a  rule,  at  different  points.  As  illustrated  in  the  cut,  the 
handle  is  arranged  with  a  crochet  needle-shaped  tip ;  back  of  the  projection 
a  slide  with  a  sharp  distal  end  is  provided,  by  means  of  which  a  small  por- 
tion of  the  engaged  tissues  may  be  caught  and  successfully  removed. 


C.TULMANN&GO.NY. 

Figure  92.    Plain  Tumor  Harpoon. 


The  Plain  Tumor  Harpoon,  shown  by  figure  92,  differs  from  the  needle 
above  described  in  being  constructed  with  a  plain  barb.  It  is  introduced 
in  the  same  manner  and  for  the  same  purpose  as  the  tissue  extractor. 


68  MECHANICAL  AIDS   IN    DIAGNOSIS. 

ASCERTAINING  SENSITIVENESS  OF  SKIN. 

The  tactile  sensibility  of  the  skin  and  amount  of  muscular  contraction 
may  be  determined  by  the  use  of  sharp-pointed  instruments  usually  called 
esthesiometers.  These  consist  of  appliances  with  two  or  more  sharp 
points  arranged  in  such  a  manner  that  they  may  be  expanded  to  any 
required  distance  from  each  other. 


Figure  93.    Sieveking's 
Esthesiometer. 


Figure  04.    Carroll's 
Esthesiometer. 


Figure  95.    Camman's 
Cardiometer. 


Sieveking's  Esthesiometer  consists,  of  a  metallic  bar  constructed  at  one 
end  with  a  sharp  arm  or  point  projecting  at  right  angles,  while  a  movable 
arm  of  similar  length  and  pattern  is  caused  to  slide  along  the  bar,  the 
distance  between  the  two  being  marked  by  graduations  on  the  latter.  By 
means  of  a  set  screw,  fixation  at  any  desired  point  may  be  secured.  It  is 
well  sketched  in  figure  93. 

Carroll's  Esthesiometer,  as  evidenced  in  figure  94,  is  a  compass-like  instru- 
ment, each  arm  of  which  is  constructed  with  a  double  point,  one  sharp,  the 
other  round,  or  bulb-shaped.  The  two  arms  are  connected  by  a  graduated 
scale  upon  which  is  marked  the  amount  of  separation  exhibited  at  the  points. 
By  substituting  one  pair  of  points  for  the  other,  sensibility  to  pain  may  be 
determined  at  different  distances  one  from  the  other  or  from  a  given  point. 

LOCATING  THE  APEX  OF  THE  HEART'S  BEAT. 

The  location  of  the  impulse  or  apex  of  the  heart's  beat  may  be  deter- 
mined by  an  instrument  called,  by  its  inventor,  a  cardiometer. 

Cardiometers. 

These  consist  of  two  arms,  each  with  points  somewhat  blunt  and  arranged 
with  mechanism  by  which  the  amount  of  separation  of  the  tips  may  be  noted. 

Camman's  Cardiometer,  as  displayed  in  figure  95,  consists  of  a  blade  and 
handle,  folding  somewhat  like  a  common  pocket-knife.  One  end  of  the 


ANTHROPOMETRY.  69 

handle  is  rounded,  while  the  other  is  sharpened  to  a  point.  The  handle  is 
graduated  in  inches  that  it  may  be  used  as  an  ordinary  rule.  The  part 
constituting  the  blade  portion  is  provided  with  a  slot  in  which  a  movable 
head  connects  with  the  handle  by  means  of  a  hinged  bar.  The  blade  is  grad- 
uated in  such  a  manner  that  the  position  of  the  movable  head  indicates  in 
inches  on  the  scale  the  spread  or  distance  between  the  point  of  the  needle 
and  the  point  of  the  blade.  By  this  instrument  any  changes  in  the  posi- 
tion of  the  apex  beat  may  be  noted. 


ANTHROPOMETRY. 

This  is  employed  not  only  as  a  means  of  diagnosing  disease,  but  for 
methods  of  detection  and  scientific  observation.  In  addition  to  the 
ordinary  instruments  described  in  diagnosis  of  the  lungs  and  chest,  the 
following  are  frequently  employed:  Dynamometers,  slide  measures, 
pelvic  obliquimeters,  calipers,  and  cranio-facial  angle  measures. 

Dynamometers. 

These  consist  of  mechanism  for  determining  muscular  power.  They 
are  employed  to  ascertain  the  degree  of  impairment  without  regard  to  the 
cause.  Usually  they  comprise  some  form  of  an  elliptical  steel  spring  with 
means  for  producing  compression,  the  amount  of  which  is  registered  in 
pounds  on  a  suitable  dial. 


Figure  96.    Mathieu's  Hand  Dynamometer. 


Figure  97.    Andrews'  Push  Dynamometer. 


Mathieu's  Hand  Dynamometer,  as  portrayed  in  figure  96,  comprises  an 
elliptical  steel  spring,  through  the  center  of  which  a  ratchet  bar  is  caused 
to  engage  a  small  cog  wheel.  A  hand  or  indicator  constructed  to  move 
around  a  semi-circular  scale  is  attached  to  the  shaft  of  the  cog  wheel.  The 
scale  is  graduated  to  show  in  pounds  the  amount  of  pressure  exerted.  As 
originally  constructed,  the  instrument  was  not  self-registering.  As  now 
manufactured,  a  friction  hand  is  provided  which,  while  it  will  move  with 
the  compression  of  the  spring,  will  remain  as  a  self-register,  indicating  the 
approximate  amount  of  pressure  in  pounds.  While  these  instruments  may 
not  be  exact  in  indicating  actual  pressure,  they  answer  perfectly  for  com- 
parative diagnosis. 

Andrews'  Dynamometers,  as  displayed  in  figures  97  and  98,  differ  in  that 
one  is  a  "push  "  and  the  other  a  "  pull  "  instrument.  The  mechanism  of 
each  is  clearly  set  forth  in  the  illustrations.  With  them  the  muscular 
power  of  the  patient  may  be  determined  and  recorded  and  the  instruments 
used  for  diagnostic  and  exercising  purposes. 


70 


MECHANICAL    AIDS     IN     DIAGNOSIS. 


The  Dynamometer  for  Ascertaining  Strength  of  Chest  and  Legs,  as  explained 
in  figure  99,  may  be  utilized  for  ascertaining  the  strength  of  the  former  by 
placing  the  elbows  extended  at  the  sides,  with  both  forearms  in  the  same 
horizontal  plane.  The  instrument  in  such  cases  should  be  held  with  the 
dial  face  outward,  the  indicator  pointing  upward,  the  patient  to  exert 
inward  force,  drawing  a  full  breath,  allowing  the  back  of  the  instrument  to 
rest  closely  against  the  chest. 

This  apparatus  may  also  be  attached  to  the  floor,  so  that  by  means  of  a 
chain  it  may  be  used  to  ascertain  the  strength  of  the  legs.  This  may  be  ac- 
complished by  shortening  the  chain,  so  that  when  the  patient  with  body  erect 
and  knees  bent  can  comfortably  grasp  the  hand  rests  at  the  proper  height, 
by  straightening  the  knees  and  lifting,  the  amount  of  strength  may  be 
noted.  It  may  also  be  utilized  to  ascertain  the  strength  of  the  muscles  of 
the  back  by  arranging  the  length  of  the  chain,  so  that  when  grasping  the 
handles  with  both  hands  and  knees  straight,  the  body  will  be  inclined  for- 
ward at  an  angle  of  60  degrees.  With  a  full  breath  and  without  bending 
the  knees,  the  lifting  power  may  be  ascertained. 


Figure  98.    Andrews'  Pull 
Dynamometer. 


Figure  99.  Andrews'  Dynamometer 

for  Ascertaining  Strength  of 

Chest  and  Legs. 


Figure  100.    Mosher's  Obliqui- 
meter. 


Kellogg's  Universal  Dynamometer,  as  shown  by  figure  103,  is  employed  for 
securing  strength  tests  in  a  variety  of  forms.  It  consists  of  a  series  of 
levers,  the  culminating  force  of  which  centers  on  a  steel  cylinder  and  piston 
in  such  a  manner  that  compression  of  the  cylinder  causes  a  column  of 
mercury  to  rise  in  the  graduated  tube,  its  height  indicating  the  amount  of 
force  employed.  The  cylinder  contains  a  fixed  quantity  of  mercury  and 
oil,  the  two  being  separated  .by  a  stratum  of  water  in  order  to  prevent 
chemical  combination.  The  scale  is  arranged  from  i  pound  to  1,000,  so  that 


ANTHROPOMETRY. 


71 


any  reasonable  amount  of  muscular  force  may  be  accurately  measured.  It 
may  be  employed  in  testing  the  flexors  and  extensors  of  the  hand,  arm,  leg, 
foot,  and  the  muscular  systems  of  the  forearm,  shoulder,  neck,  etc 


Slide  Measures. 


These  are  employed  for  ascertaining  the  figure  height  and  the  breadth  or 
depth  at  various  points.  Height  measures  may  be  permanently  attached 
to  the  wall,  or  of  some  movable  design.  The  breadth  measure  of  the 
head,  neck,  shoulders,  waist,  hips,  nipples,  etc.,  may  be  secured,  while 
depth  measures  may  be  taken  of  the  chest,  abdomen,  etc. 

The  Height  Measure,  illustrated  by  figure  101,  consists  of  a  bar  graduated 
in  feet  and  inches,  along  which  a  sliding  marker  may  be  moved  back  and 
forth.  When  in  service  the  bar  is  usually  fastened  against  a  wall  in  such  a 
manner  that  the  marker  may  be  placed  against  the  top  of  the  head  of  the 
patient  to  be  measured.  The  exact  height  will  be  indicated  on  the  scale. 


G.TIEMANN&CO. 


Figure  101.    Height  Measure. 


Figure  102.    French  Pattern 
Anthropometer. 


Figure  103.     Kellogg's  Universal 
Dynamometer. 


The  French  Pattern  Anthropometer,  illustrated  by  figure  102,  consists  of  a 
sliding  measure  somewhat  similar  to  that  used  by  shoemakers  in  taking 
measurements  of  the  foot.  A  short  bar  about  6  inches  in  length  is  securely 
fastened  at  right  angles  to  a  graduated  section  about  30  inches  long.  A 
sliding  bar  with  its  face  also  at  right  angles  to  the  main  shaft  and  parallel 
with  its  mate,  may  be  moved  backward  and  forward  as  desired.  With 
this,  various  measurements  of  the  body,  lengths,  breadths,  diameters,  etc., 
may  be  quickly  and  accurately  taken. 


72 


MECHANICAL    AIDS    IN     DIAGNOSIS. 


Obliquimeters. 

These  consist  of  arms  employed  to  indicate  the  angle  formed  by  compar- 
ing the  plane  of  the  pelvic  brim  with  the  perpendicular  axis  of  the  upright 
body. 

Mosher's  Obliquimeter  consists  of  two  arms,  one  stationary,  the  other 
movable.  In  use  the  former  should  be  placed  with  its  point  at  the  sacro- 
lumbar  articulation,  the  latter  at  the  top  of  the  pubes.  By  this  adjustment 
the  angle  acquired  by  the  brim  of  the  pelvis  will  be  indicated  by  a  needle 
or  arm  upon  a  semi-circular  scale  provided  for  that  purpose.  It  may  be 
employed  by  gynecologists  and  directors  of  gymnasiums  for  females.  In 
the  latter  institutions,  it  may  enable  instructors  to  correct  abnormal  poses 
in  certain  cases,  thereby  overcoming  a  tendency  toward  diseased  conditions. 
The  apparatus  is  well  pictured  in  figure  100. 

Calipers. 

These  consist  of  projecting  arms,  either  hinged  or  sliding  upon  a  fixed 
bar  and  arranged  with  mechanism  for  determining  the  distances  between 
the  arm  tips.  They  are  employed  in  various  forms  of  mensuration,  their 
principal  use  being  to  accurately  ascertain  various  cranial  measurements. 


Figure  1M.    Peterson's  Caliper. 


Figure  105.    Stearns'  Cranio-Facial  Angle  Instrument. 


Peterson's  Caliper,  as  exhibited  in  figure  104,  comprises  a  straight,  flat, 
graduated  bar,  to  one  end  of  which  a  curved  arm  with  bulbous  tip  is  at- 
tached by  set  screw.  A  second  arm,  shaped  like  the  first,  is  arranged  to 
slide  along  the  bar,  fixation  at  any  point  being  secured  by  a  set  screw. 
Both  arms  are  curved  on  the  edge  with  their  concave  faces  inward. 

Cranio-Facial  Angle  Instruments. 

A  study  of  the  cranio-facial  angles  as  a  means  of  determining  degenera- 
tion in  the  insane,  may  be  assisted  by  special  instruments  constructed  for 
this  purpose 

Stearns'  Cranio-Facial  Angle  Instrument,  as  shown  by  figure  105,  is  an 
appliance  for  obtaining  the  angle  formed  by  two  lines,  one  joining  the 


URINARY    ANALYSIS.  73 

naso-frontal  suture  and  the  most  prominent  point  of  the  lower  edge  of  the 
superior  alveolar  process,  and  the  other  joining  the  superior  border  of  the 
external  auditory  meatus  and  the  lower  border  of  the  orbit.  It  can  be  em- 
ployed upon  the  living  subject  and  furnishes  means  for  obtaining  accurate 
measurements.  It  consists  of  a  slotted  bar,  to  one  side  of  which  a  semi- 
circular scale  is  attached.  This  scale  is  graduated,  showing  the  arc  of  any 
given  circle. 

Two  parallel  adjustable  arms  project  at  right  angles  from  the  bar,  each 
movable  along  the  slot  previously  mentioned.  A  lever  or  arm  fixed  in  the 
center  of  the  slotted  bar  and  in  the  center  of  the  circle,  marks  upon  the 
scale  the  angle  secured.  By  placing  this  arm  so  that  its  upper  border  rests 
on  a  level  with  the  superior  border  of  the  external  auditory  meatus  and  the 
lower  border  of  the  orbit,  and  then  adjusting  the  two  movable  arms  so  that 
one  rests  on  the  root  of  the  nose  and  the  other  on  the  gum  over  the  roots 
of  the  upper  incisors,  the  facial  line  will  be  projected  into  the  same  plane 
with  the  basal  line  of  the  cranium,  and  the  angle  formed  by  the  meeting  of 
these  two  lines  will  be  indicated  upon  the  scale. 


URINARY  ANALYSIS. 

Under  this  head  we  will  include  only  the  more  common  forms  of  appa- 
ratus employed  in  urine  examination,  omitting  all  reference  to  details  or  to 
the  drugs  and  chemicals  used  in  the  various  processes. 
The  apparatus  usually  employed  consists  of 
Test  tubes  Beakers 

Test  tube  swabs          Acid  bottles 
Test  tube  holder         Evaporating  dishes 
Test  tube  rack  Burettes  and  holders 

Measuring  glass          Sediment  tube 
Droppers  Conical  test  glass 

Pipette  Wine  Collamore  glass 

Alcohol  lamp  Filter  paper 

Bunsen  burner  Litmus  paper 

Chemical  flask  Tripod 

Funnels  Blow  pipe 

Test  Tubes,  as  portrayed  by  figure  106,  consist  of  cylinders  of  fine  glass, 

one  end  rounded,  the  other  open  and -slightly  enlarged  in  bell  form.     They 

are  employed  for  holding  liquids  while  being  heated,  for  precipitation  and 

many  other  chemical  processes.     They  may  be  obtained  nested  of  various 

sizes,  those  from  three  to  six  inches  in   length   being  usually  preferred. 

These  sizes  are  best  adapted  for  general  use,  and  this  method  of  packing 

furnishes  a  safe  and  compact  means  for  transportation.     While  the  sizes 

vary  with  different  makers,  they  are  usually  as  follows: 

Length  3  inches.      Diameter  Tcff  inches. 

"        4       "  A       " 

"       5       "  "         A-       " 

"       6       "  "         H       " 

it         a        ti  tc  .< 

8  if 

Test  Tube  Swabs  usually  consist  of  slender  wood  sticks,  to  which  a  swab  of 

cotton  or  gauze  is  attached.     They  are  employed  to  assist  in  cleansing  test 
tubes  and  other  chemical  apparatus. 


74 


MECHANICAL    AIDS     IN     DIAGNOSIS. 


Test  Tubes  on  Foot,  as  illustrated  by  figure  107,  differ  from  the  ordinary 
pattern  in  being  of  heavier  material  and  provided  with  a  small  foot,  by 
means  of  which  they  will  stand  independent  of  a  rack  or  other  support. 
They  are  employed  principally  as  sedimentation  tubes.  The  size  most 
common  in  use  is  ^  inch  in  diameter  and  5  inches  in  height. 

Test  Tubes  Graduated,  as  exhibited  by  figure  108,  differ  from  the  pattern 
first  described  only  in  being  supplied  with  graduations,  by  means  of  which 
they  may  be  used  as  measuring  glasses.  While  all  sizes  can  be  purchased 
in  this  form,  those  usually  found  on  the  market  are  5  and  6  inches  in  length. 


if 

Figure  106. 


^ 


-^1—  -^ 

CG 
EOT 

v> 

^  *s 

GC 
GO'F 

450  2 

| 

450^ 

4DD4E 

5 

400^ 

35015 

I 

35D^P 

3::  — 

1 

3DD-S 

250-5 

B 

25Q-H 

ZBO-5 

Z[0-g 

153  -?f 

ISQ-g 

t     ~  1 

6i     /< 

s:  — 
t     .1 

Test  Tubes.    Figure  107.    Test  Tube 
on  Foot. 


Figure  108.    Graduated 
Test  Tube. 


Figure  109.    Measuring 
Glasses. 


Measuring  Glasses,  as  shown  by  figure  109,  consist  of  graduated  cylinders 
resting  on  small  feet,  by  means  of  which  they  are  held  in  an  upright  posi- 
tion. They  are  graduated  and  can  be  obtained  of  various  sizes  holding  from 
250  to  1000  c.c.  Usually  they  are  in  two  forms,  either  open  and  with  a 
small  lip  or  beak  by  which  their  contents  may  be  easily  poured  off,  or 
supplied  with  necks  and  stoppers  in  ordinary  bottle  form. 

Test  Tube  Racks,  as  evidenced  by  figure  no,  consist  of  one  or  more  per- 
forated shelves,  by  means  of  which  plain  test  tubes  may  be  held  in  an  up- 
right position.  Usually  two  sets  of  openings  are  provided,  that  tubes  of 
different  sizes  may  be  accommodated.  Many  patterns  are  constructed  with 
a  series  of  pins  5  or  6  inches  in  length,  over  which  test  tubes  may  be 
inverted,  either  for  draining  or  storage.  This  feature  is  an  advantage 
because  the  tubes  are  not  likely  to  accumulate  foreign  matter  while  in  this 
position.  Usually  such  racks  accommodate  from  10  to  20  tubes.  The  pat- 
terns from  various  makers  differ  in  shape  and  size. 

Test  Tube  Holders  may  vary  from  the  ordinary  spring  wooden  clothes  pin 
or  wire  clamp  to  the  special  pattern  depicted  by  figure  113.  The  latter  is 
practically  of  the  old-fashioned  clothes-pin  type,  excepting  that  one  end  is 
elongated  so  as  to  form  a  handle,  while  the  jaws  are  held  together  by 
means  of  a  rubber  band. 

Pipettes,  as  set  forth  in  figure  114,  are  slender  glass  tubes  constricted  at 
one  end  in  such  a  manner  as  to  permit  the  gradual  escape  of  any  contained 
fluid.  They  are  usually  of  two  patterns,  either  plain  or  with  a  rubber  com- 


URINARY    ANALYSIS. 


75 


pression  bulb.  In  the  former  patterns  the  tube  must  be  of  sufficient  length 
that  it  may  be  immersed  in  the  fluid  to  such  an  extent  that  by  simple 
closure  of  the  open  end  with  the  finger,  the  requisite  amount  may  be  with- 
drawn within  the  pipette.  Liberation  may  be  secured  by  removal  of  the 
finger. 


Figure  111.    Straight  Medicine  Dropper. 


<f 


Figure  110.    Test  Tube  Rack. 


Figure  112.    Curved  Medicine  Dropper. 


A  more  popular  pattern  is  that  shown  by  figure  114.  With  this  it  is 
only  necessary  to  compress  the  rubber  bulb  and  pass  the  tip  of  the  instru- 
ment below  the  surface  of  the  liquid.  By  releasing  the  bulb  pressure  the 
tube  will  fill,  after  which  the  contents  may  "be  expressed  by  bulb  pressure. 
These  tubes  may  be  either  graduated  or  plain,  the  latter  being  usually 
called  droppers. 


Figure  113.    Test  Tube  Holder. 


Figure  114.    Graduated  Pipette. 


Droppers,  as  delineated  in  figures  in  and  112,  do  not  differ  from  the  pat- 
tern of  pipette  last  described  excepting  that  they  are  not  graduated.  They 
may  be  either  plain  or  curved.  They  are  used  for  mixing  or  dropping  small 
quantities  of  fluid  and  for  ma&ingr  applications  to  the  eyes,  etc. 

Urinometers  are  a  fori>«  of  hydrometer  used  to  determine  the  specific 
gravity  of  urine.  Usually  the\  '•^tris.ter'frorn  1000  to  1040.  All  should  be 
tested  before  acceptance  from  the  deale",  In  plooing  them  in  distilled  water 
at  60°  Fahr.,  in  which  they  should  sink  to  She-  joob  mark.  Generally  they 
are  graduated  for  use  at  this  temperature,  m  ^fihich  case  the  fluid  to  be 
tested  should  be  as  near  this  temperature  as  possible.  Some  are  supplied 
with  thermometers,  an  advantage  claimed  by  many  authors.  Accuracy  in 
marking  is  essential.  If  a  urinometer  reading  means  anything,  it  should  be 
of  known  correctness,  and  purchasers  should  see  that  they  are  supplied 
with  perfect  instruments. 

The  Plain  Urinometer,  as  pictured  by  figure  115,  consists  practically  of 
three  parts ;  a  small  bulb  for  the  mercury  or  other  substance  used  as  a 
weight  to  sink  the  instrument  below  the  surface  of  the  fluid  to  be  tested ; 
an  air  chamber  by  means  of  which  the  tube  is  floated  and  maintained  in  an 
upright  position ;  and  a  slender  tube  or  bar  extending  above  the  surface  of 
the  fluid  and  upon  which  is  graduated  the  reading  scale.  These  uprights 
are  of  two  forms,  either  tubular,  in  the  center  of  which  a  paper  with  gradua- 
tion marks  the  proper  readings,  or  a  flattened  glass  bar,  upon  the  outer 
surface  of  which  the  graduations  are  marked. 

The  Urinometer  and  Graduated  Test  Glass,  as  portrayed  by  figure  116,  pos- 
sesses no  special  features  other  than  that  the  container  is  graduated  and 
the  scale  of  the  urinometer  of  white  glass,  the  markings  being  in  black 
and  plainly  legible. 


76 


MECHANICAL    AIDS     IN     DIAGNOSIS. 


Squibb's  Urinometer,  as  designed  in  figure  117,  is  standardized  for  use  at 
70°  Fahr.  The  special  feature  of  this  instrument  is  the  glass  containing 
jar,  which  is  fluted  so  that  the  urinometer  will  not  cling  to  the  sides  of  the 
chamber  because  of  capillary  attraction.  The  air  chamber  is  conical 
both  ends,  thus  facilitating  a  free  perpendicular  movement. 


at 


Figure  115.    Ordinary  Urinometer. 


Figure  116.    Urinometer  with 
Graduated  Test  Glass. 


Figure  117.    Squibb's  Pattern 
Urinometer. 


The  Alcohol  Lamp,  as  traced  by  figure  118,  is  a  form  of  spirit  lamp  used 
for  heating  purposes.  Usually  it  consists  of  a  small  glass  globe  of  2  or  4 
ounce  capacity,  with  a  wick  and  glass  cover  or  cap. 

Bunsen's  Burner,  as  exhibited  by  figure  119,  consists  of  a  burner  wherein 
ordinary  gas  is  so  mixed  with  air  so  as  to  produce  oxidation  and  an  improved 
combustion. 

The  Chemical  Flask,  as  outlined  by  figure  120,  consists  of  a  spherical 
bottle  with  a  long,  narrow  neck.  They  are  sometimes  called  receiving 
glasses,  and  are  used  in  various  chemical  procedures.  In  urinary  analysis 
they  are  employed  for  storing  the  whole  volume  of  urine  passed  in  24  hours, 
in  order  not  only  to  ascertain  the  full  quantity  passed  in  that  time,  but  also 
to  secure  a  sample  that  is  a  fair  average  of  the  whole.  For  this  purpose 
the  flask  should  hold  about  two  litres.  They  may  be  obtained  of  almost 
any  size,  varying  from  one  ounce  to  several  gallons. 

Funnels  may  be  described  as  open,  inverted,  conical-shaped  vessels,  the 
bottoms  of  which  terminate  in  slender  tubes.  They  are  used  to  guide 
liquids  when  being  transferred  from  one  vessel  to  another,  or  as  a  support 
for  filter  papers,  etc.  The  lower  end  of  the  tube  may  be  either  plain  or 
obliquely  ground,  as  pictured  in  figure  121.  They  may  be  obtained  of 
any  desired  size,  from  one-ounce  capacity  to  that  of  several  pints. 

Beakers,  as  delineated  by  figure  122,  consist  of  wide-mouth  cup-shaped 
vessels  with  straight  sides  and  flat  bottoms.  They  are  employed  for  the 
storage  and  mixing  of  liquids.  They  may  be  purchased  with  or  without  a 
lip,  and  in  sizes  varying  from  one  ounce  to  several  pints.  For  urinary 
analysis  they  may  be  procured  nested,  the  sizes  generally  employed  con- 
sisting of  i,  2,  3  and  4  ounce  capacity. 


URINARY    ANALYSIS. 


77 


Acid  Drop  Bottles,  as  displayed  by  figure  123,  consist  of  a  small  flask  wiih 
slender  neck  and  small  mouth,  the  latter  containing  a  ground  glass  stopper, 
the  under  portion  of  which  terminates  in  a  slender  glass  rod  provided  with 
a  sharp  pointed  tip,  the  latter  extending  to  the  bottom  of  the  flask.  They 
are  employed  in  making  chemical  tests,  where  only  a  limited  number  of 
drops  are  required.  Fluid  by  adhering  to  the  rod  will  drop  from  the  point 
when  the  stopper  is  removed  from  the  bottle. 


Figure  118.    Alcohol 
Lamp. 


Figure  119.    Bunsen 
Burner. 


Figure  120.    Chemical 
Flask. 


Figure  121.     Glass 
Funnel. 


Evaporating  Dishes,  as  depicted  in  figure  124,  are  shallow,  round  bottomed 
vessels  used  to  hold  liquids  while  they  are  being  evaporated  or  melted. 
Ordinarily  they  are  manufactured  from  porcelain  and  are  provided  with  a 
lip  to  facilitate  the  pouring  off  of  any  contained  liquid.  They  may  be 
procured  of  any  size  from  one  ounce  to  several  pints. 

Ordinary  Watch  Crystals  are  also  employed  as  evaporating  dishes. 
These  do  not  differ  from  the  watch  glasses  sold  in  jewelry  stores.  They 
are  employed  in  urinary  analysis  for  evaporating  small  quantities  of  liquids. 

Litmus  Paper  may  be  either  blue  or  red,  the  former  when  placed  in  an 
acid  solution  turning  red,  and  the  latter  in  an  alkali  solution  turning  blue. 
When  of  good  quality,  they  are  delicate  and  will  show  a  slight  percentage 
of  acid  or  alkali.  They  may  be  procured  in  sheet  form,  in  strips,  or  cut 
into  small  books,  as  outlined  by  figure  125. 


Figure  122.  Beakers. 


Figure  123.  Acid  Figure  124.  Porcelain 
Drop  Bottle.      Evaporating  Dishes. 


Figure  125.     Litmus  Paper. 


Burettes,  as  traced  by  figure  126,  consist  of  slender  graduated  glass  tubes, 
employed  to  measure  small  quantities  of  fluid  usually  while  one  is  being 
mixed  with  another.  As  shown  by  the  figure,  they  may  be  either  plain  or 
with  stop  cock.  They  are  generally  purchased  in  connection  with  some 
form  of  holder  by  means  of  which  the  tube  may  be  maintained  in  a  firm 


78 


MECHANICAL    AIDS     IN     DIAGNOSIS. 


yet  upright  position.  Usually  they  hold  about  100  cc. ,  this  being  the  size 
best  adapted  for  urinalysis.  They  may,  however,  be  obtained  of  any 
desired  capacity. 

Conical  Test  Glasses,  as  exhibited  by  figure  127,  resemble  small  wine- 
glasses, the  principal  difference  being  that  the  bowl  is  in  conical  form, 
the  better  to  collect  sediments  more  highly  condensed  than  would  be  possi- 
ble in  a  flat-bottomed  vessel. 

Wine  Collamore  Glasses,  as  portrayed  by  figure  128,  are  a  form  of  ordi- 
nary wineglass.  They  are  advised  by  some  authors  for  use  in  precipitat- 
ing fluids,  and  as  receptacles  in  which  to  mix  various  samples  in  testing. 


Figure  126.    Burettes.    Figure  127.    Conical 
Test  Glass. 


Figure  128.    Wine  Collamore 
Glass. 


Figure  129.    Webster's 
Sediment  Tube. 


Webster's  Sediment  Tube,  as  illustrated  by  figure  129,  is  intended  for  use 
in  cases  where  a  centrifuge  is  not  at  hand.  It  consists  of  a  heavy  glass 
cylinder  constricted  to  a  fine  point  at  its  lower  end  and  the  latter  left  open. 
By  closing  the  small  opening  at  the  bottom  with  the  finger  or  other  sub- 
stance, the  tube  may  be  partially  filled  and  the  cork  inserted,  after  which,  if 
the  lower  end  be  kept  free  from  contact  with  any  foreign  substance,  the 
liquid  will  remain  within  the  tube  until  the  removal  of  the  cork.  In  pre- 
cipitating urine,  it  may  be  allowed  to  stand  until  pus,  casts  and  other 
deposits  have  settled  in  the  bottom  of  the  tube.  By  placing  the  point  over 
a  glass  slide  and  slightly  pressing  on  the  cork,  a  single  drop  of  the  con- 
densed liquid  may  be  forced  upon  the  slide. 

Tripods  or  other  supports  are  convenient  where  it  is  necessary  to  heat 
evaporating  dishes,  chemical  flasks,  etc.  They  are  used  as  a  stand  for  a 
container,  that  it  may  be  held  at  a  proper  position  above  the  lamp  flame. 

Blow  Pipes  are  occasionally  used  in  various  chemical  processes.  The 
ordinary  jeweler's  form  will  answer  every  purpose. 

Doremus'  Ureometer,  as  illustrated  by  figure  130,  consists  of  a  cylindrical 
tube  closed  at  one  end,  the  other  enlarged  into  a  spherical  bulb  with  a 
bottle-shaped  neck.  Just  below  the  globular  portion  of  the  cylinder,  the 
tube  is  bent  at  an  angle  of  about  45°.  As  thus  designed,  the  tube  may 
be  mounted  on  a  foot  or  base.  The  latter  is  preferable,  as  it  serves  to 
keep  the  instrument  in  an  upright  position.  A  recent  improvement,  shown 
in  figure  131,  consists  in  attaching  a  side  tube  with  an  upward  curve  to  the 
main  or  straight  portion  of  the  cylinder.  This  tube  near  its  lower  border 
is  supplied  with  a  stop-cock.  This  pattern  of  ureometer  is  employed  to 


URINARY     ANALYSIS. 


79 


ascertain  the  quantity  of  urea  in  a  given  specimen  of  urine  by  decomposing 
the  urea  by  the  addition  of  sodium  hypobromite,  and  estimating  the  quan- 
tity present  by  the  volume  of  nitrogen  gas  resulting.  The  latter  is  shown 
by  a  graduated  scale  carefully  prepared.  In  the  old  style  of  instruments 


-ID 


Figure  1.30.     Doremus' 
Original  Ureometer. 


Figure  131.     Doremus' 
Improved  Ureometer. 


Figure  132.  Einhorn's  Figure  133.  Esbach's 
Saccharometer.  Albuminometer. 


the  bromine  solution  was  added  by  means  of  a  curved  pipette  introduced 
through  the  short  open  neck.  In  the  new  pattern  this  solution  is  placed  in 
the  side  tube  and  allowed  to  unite  with  the  urine  by  turning  the  stop  cock 
before  mentioned.  Full  directions  should  accompany  each  instrument. 

Einhorn's  Saccharometer  is  similar  in  construction  to  the  ordinary  pattern 
of  ureometer.  As  represented  in  figure  132,  it  is  supplied  with  a  scale  and  is 
used  to  estimate  the  quantity  of  sugar  in  a  given  specimen  of  urine  by  what 
is  known  as  the  fermentation  test.  In  this  process  a  good  quality  of  yeast 
is  employed.  Two  tests  should  be  made  at  the  same  time,  one  on  normal,  the 
other  on  suspected  urine,  because  the  yeast  at  times  may  give  rise  to  some 
gas  even  when  no  sugar  is  present.  Directions  usually  accompany  each 
instrument. 

Esbach's  Albuminometer,  as  exhibited  by  figure  133,  is  employed  for  the 
estimation  of  albumin  by  precipitation  with  picric  acid.  It  consists  of  a 
heavy  test  tube  with  special  graduations,  the  neck  being  closed  with  a  rubber 
stopper.  This,  as  well  as  the  two  instruments  previously  described,  should 
not  be  purchased  unless  accompanied  with  satisfactory  directions. 

Robert's  Urine  Test  Apparatus,  as  exhibited  in  figure  134,  consists  of 

1  set  Neubauer's  urinometers      i  burette 

2  test  glasses  for  same 

4  urine  glasses 
6  test  tubes 

i  alcohol  lamp 

5  bottles  filled  with  re-agents 


i  burette  holder 

3  pipettes 

3  stirring  rods 

i  graduate 

i  flask  with  ring  support 


All  neatly  arranged  in  a  stand,  as  shown  in  the  illustration. 


80 


MECHANICAL  AIDS   IN   DIAGNOSIS. 


Bartley's  Pocket  Urine  Test  Case,  as  set  forth  by  figure  135,  consists  of  a 
small,  oval,  hard  rubber  case,  surmounted  by  a  metallic  cap,  the  latter  con- 
structed in  the  form  of  a  reservoir  and  provided  with  two  wicks  that  it  may 
be  employed  as  an  alcohol  lamp.  The  whole  case,  including  lamp,  is  only 
51^  inches  in  length,  1%;  inches  in  breadth,  and  fa  inch  in  thickness. 


Figure  134.    Robert's  Urine  Test  Apparatus. 


Figure  135.     Bartley's  Pocket 
Urine  Test  Case. 


The  case  also  contains  one  bottle  of  sugar  test  in  powder,  one  bottle 
albumin  test  in  powder,  one  small  yet  accurate  urinometer,  one  pipette 
with  nipple,  one  test  tube,  one  scoop  for  handling  powders  and  a  package 
each  of  red  and  blue  litmus  paper. 

Me  Williams'  Urine  Test  Case,  as  outlined  by  figure  136,  is  one  of  the 
cheapest  and  yet  most  practical  cases  on  the  market.  The  box  is  of  com- 
mon material,  plainly  finished.  The  case  contains 

i  jar  litmus  paper,  red  and  blue 

i  jar  matches 

1  bottle  cupric  sulphate  solution 

2  bottles   for  bichloride  water   and 
droppers 

i  tablet  of  paper 
i  urinary  analysis  guide  book 
i  glass  stirring  rod 
lead  pencil  with  eraser 


i  3-ounce  lamp  with  wick  and  alcohol 

i  urinometer 

10  test  tubes 

i  test  tube  holder 

i  stick  wrapped  with  cotton 

i  fine  pointed  nipple  pipette 

i  fine  pointed  cubic  centimeter  pipette 

i  bottle  nitric  acid 

i  bottle  with  funnel 

i  bottle  sodio-potassic-tartrate  solution    12  filter  papers 

The  Author's  Original  Urine  Test  Case  is  of  hard  wood  and  constructed 
on  a  principle  which  possesses  many  advantages.  The  upper  part,  which 
forms  the  test  tube  rack  when  in  use,  can  be  closed  down  and  fastened; 


URINARY     ANALYSIS. 


81 


the  hollow  slats  holding  the  funnels  will  slide  into  the  case,  the  drawer  can 
be  returned  to  its  socket,  thus  forming  a  neat,  compact  box  that  guards  its 


Figure  136.    McWilliams'  Urine  Test  Case.  Figure  137.    Author's  Original  Urine  Test  Sel. 

contents  from  breakage  and  protects  them    from  the  injurious  effects  of 
dust,  light  and  air.     As  displayed  in  figure  137,  it  contains 

8  re-agent  bottles  2  glass  funnels 

Alcohol  lamp  2  beakers 

Porcelain  evaporating  dish         2  small  glass  evaporating  dishes 

14  test  tubes,  assorted  sizes        Test  tube  holder 

Urinometer  Graduated  pipette 

Filter  Litmus  paper 

Small  book  on  urinary  analysis 


Figure  138.     Author's  Improved  Urine  Test  Case. 

The  Author's  Improved  Urine  Test  Case,  as  delineated  in  figure  138,  com- 
prises an  extensive  outfit  for  both  qualitative  and  quantitative   analysis. 
Several  modern  appliances  are  included  that  tend  to  facilitate  the  work. 
The  case  is  so  arranged  as  to  economize  space  and  contains 
G 


82 


MECHANICAL    AIDS     IN    DIAGNOSIS. 


i  Einhorn's  saccharometer  with  di- 
rections 

i  ureometer  with  directions 
i  Esbach's  albuminometer 
i  thermometer  (not  self -registering) 

1  best  urinometer  with  graduated  jar 

2  conical  test  glasses 

i  wine  Collamore  glass 

3  stirring  rods 

1  dozen  test  tubes 

2  test  tubes  on  foot 
i  test  tube  swab 

i  nest  beakers,  i  to  6  ounces 
i  book  on  urinary  analysis 


The  box  is  of  hard  wood,  plainly  finished. 


i  graduate,  i  ounce 

i  drop  bottle 

i  pair  brass  forceps 

i  glass  funnel 

i  alcohol  lamp 

i  porcelain  evaporating  dish 

3  small  glass  evaporating  dishes 

i  folding  wire  tripod 

1  graduated  pipette 

8  re-agent  bottles  (7  of  them  filled) 

2  wide  mouth  glass  stoppered  bottles 
2  small  glass  stoppered  vials 

6  filter  papers 

i  book  litmus  paper,  red  and  blue 


CHAPTER  III. 


TRANSPORTATION   OF   PATIENTS. 

The  problem  of  how  best  to  transport  the  sick  and  injured  to  the  hos- 
pital and  from  ward  or  apartment  to  and  from  the  operating-room,  has 
commanded  the  attention  of  many  of  our  ablest  mechanics.  Patients  weak 
from  illness  or  injury,  and  perhaps  suffering  from  inflammatory  conditions, 
require  and  rightfully  demand  the  highest  possible  degree  of  comfort  and 
convenience  that  science  and  money  can  bring  to  their  aid. 

The  combined  skill  of  the  instrument  and  wagon  maker,  directed  and 
assisted  by  the  physician  and  surgeon,  has  resulted  in  the  construction  of 
appliances  so  varied  in  form  and  character  as  to  successfully  meet  all  de- 
mands. 

The  appliances  available  for  transporting  patients  are  ambulances, 
wheel  litters  and  hand  stretchers. 

Ambulances. 

These  consist  of  covered  vehicles,  usually  with  four  wheels,  especially 
constructed  for  conveying  patients  in  a  recumbent  position.  They  are  of 
French  origin  and  are  said  to  have  been  invented  by  Baron  Percy,  who 
designed  them  for  transporting  the  wounded  from  the  field  of  battle.  They 
are  of  two  varieties:  Horse  and  bicycle  or  tricycle  ambulances. 


Figure  139.    St.  Luke's  Hospital  (Chicago) 
Ambulance. 


Figure  140.    Plain  Ambulance. 


The  St.  Luke's  Hospital  Ambulance,  as  pictured  in  figure  139,  is  of  a  new 
design,  one  that  will,  we  believe,  become  popular  when  once  its  advantages 
are  known.  As  it  is  constructed  with  Collinge  axles,  the  body  rides  close 
to  the  ground,  thus  avoiding  much  of  the  swinging  motion  common  to 
other  vehicles.  The  main  portion  of  the  body  is  suspended  by  rubber-head 
C  springs,  while  the  driver's  box  rests  upon  platform  springs  of  great  elas- 
ticity. The  body  is  of  wood,  neatly  paneled  and  provided  with  good  ven- 
tilation. The  rear  doors  are  double  and  swing  in  either  direction.  The 
inside  seats  are  so  built  that  they  may  be  out  of  the  way  when  not  required 
for  use.  Lights  are  provided  for  both  inside  and  outside  use.  Three 
forms  of  stretchers  may  be  utilized,  one  suspended,  a  second  of  wicker 

83 


84  TRANSPORTATION     OF    PATIENTS. 

work,  and  a  third  of  the  ordinary  floor  pattern.     It  is  supplied  with  rubber 
tires. 

The  Plain  Ambulance,  as  it  appears  in  figure  140,  illustrates  one  of  the 
many  forms  that  may  be  found  in  the  market.  The  body  is  hung  on  soft, 
easy  riding  platform  springs,  and  the  wheels  are  provided  with  rubber  tires, 
thus  insuring  the  highest  degree  of  comfort.  A  portion  of  the  side  is 
arranged  with  a  heavy  roll-up  curtain,  while  the  solid  woodwork  is  of 
plain  construction,  that  it  may  be  easily  cleansed  and  disinfected.  The  end 
gate  is  constructed  to  drop,  and  the  step  in  the  rear  is  provided  with  a  rub- 
ber cover.  Lamps  are  arranged  for  throwing  light  ahead  of  the  vehicle, 
as  well  as  illuminating  the  interior.  A  medicine  drawer  is  provided  under 
the  driver's  seat,  and  two  folding  benches,  each  convenient  to  the  patient, 
are  arranged  for  the  use  of  the  physicians.  Stretchers  can  be  obtained  in 
various  forms,  suspended  or  otherwise.  They  may  be  of  wicker  work,  can- 
vas or  elastic  springs. 


Figure  141.     Binkley's  Tricycle  Ambulance. 

Binkley's  Tricycle  Ambulance,  as  represented  in  figure  141,  is  an  im- 
proved form  for  the  transportation  of  the  sick  and  injiired.  Heretofore 
this  service  has  been  rendered  by  the  use  of  ordinary  ambulance  wagons, 
the  sight,  or  often  the  thought,  of  which  has  proven  a  source  of  dread  to 
many  an  invalid.  The  appliance  here  shown  furnishes  a  satisfactory  relief 
in  this  respect.  The  hospital  staff,  if  equipped  with  one  of  these  machines, 
may  immediately  dispatch,  on  a  moment's  notice,  without  waiting  for  the 
harnessing  of  horses  and  preparation  of  driver,  a  neat,  attractive,  comfort- 
able and  noiseless  vehicle.  It  not  only  furnishes  more  prompt  assistance, 
but  a  more  comfortable  bed  on  which  to  transport  the  patient. 

The  first  of  these  ambulances  was  constructed  in  1896  for  use  in  the 
Chicago  Hospital,  and  during  its  first  day  in  service  it  made  twelve  satisfac- 
tory runs.  After  two  years  of  active  use  it  has  been  found  much  cheaper 
to  maintain  and  so  satisfactory  to  the  afflicted,  that  it  has  entirely  replaced 
the  wagon  ambulances  formerly  employed. 

As  now  constructed,  it  consists  of  an  oval-shaped  top  and  front,  resting 
on  light  elastic  springs,  the  whole  mounted  on  a  tricycle  frame  similar  in 
construction  to  a  tandem  bicycle.  The  body  is  large,  well  ventilated,  sup- 
plied with  windows,  electric  lights  and  all  modern  conveniences.  The 
patient  rests  on  a  pneumatic  bed  arranged  in  stretcher  form,  the  latter  so 
designed  that  immediately  upon  withdrawing  it  from  the  chamber,  two  sets 
of  legs  or  supports  automatically  attached  are  brought  into  service.  These 
terminate  in  4-inch  rubber-tired  wheels  in  such  a  manner  that  the  stretcher 
is  at  once  converted  into  a  wheel  litter.  A  second  electric  lamp,  supplied 
by  a  storage  battery,  is  placed  in  the  front  of  the  machine. 

In  cities  where  street  grades  permit,  this  apparatus  should  prove  popu- 
lar, as  the  expense  of  purchasing,  feeding  and  caring  for  horses  need  no 
longer  be  incurred. 


WHEEL    LITTERS. 


85 


Wheel  Litters. 

A  wheel  litter  consists  of  a  barrow,  provided  with  two,  three  or  four 
wheels,  and  an  upper  framework  upon  which  rests  a  removable  stretcher. 
They  are  principally  employed  to  convey  patients  from  ward  or  apartment 
to  the  operating-room  and  return.  When  intended  for  indoor  use,  they  are 
of  light  construction,  and  narrow  enough  to  admit  of  passage  through  door- 
ways of  ordinary  width.  The  better  ones  are  manufactured  from  wrought 
iron  and  provided  with  rubber  tires.  Heavy  patterns  are  occasionally  em- 
ployed in  exposition  grounds  and  work  yards,  in  which  case  they  are  usually 
constructed  with  a  canopy. 


Figure  141A.    Binkley's  Tricycle  Ambulance. 


Figure  142.    Chicago  Wheel  Litter. 


The  Chicago  Wheel  Litter,  as  depicted  in  figure  142,  by  reason  of  its  low 
price  and  because  in  many  cases  it  is  steady  enough  for  use  as  an  operating 
table,  is  more  universally  employed  than  any  other  design  of  which  we  have 
any  knowledge.  The  frame  is  of  wrought  iron,  strongly  braced,  and  when 
of  good  manufacture,  it  will  sustain  and  carry  a  weight  of  600  pounds.  This 
frame  rests  on  two  24-inch  and  two  1 2-inch  rubber-tire,  steel-suspension 
wheels,  the  latter  pivoted  in  such  a  manner  that  they  will  turn  in  any  direc- 
tion, thus  admitting  of  moving  the  litter  in  a  short  circle.  The  stretcher 
is  removable  and  in  the  form  of  a  table- top,  and  is  constructed  either  of 
polished  hard  wood  or  padded  and  covered  with  oilcloth.  Its  length  is  72, 
height  34  and  width  26  inches;  it  thus  passes  easily  through  an  ordinary 
28-inch  door-frame. 

The  German  Wheel  Litter,  illustrated  in  figure  143,  is  constructed  with 
a  wrought  iron  frame  of  unusual  strength  and  rigidity.  The  legs,  cross 
and  side-bars  are  also  of  wrought  iron  and  firmly  united  at  every  junc- 
tional  point.  The  frame  is  securely  mounted  on  a  steel  axle  and  is  borne 
upon  two  24-inch  rubber-tire,  steel-suspension  wheels.  To  avoid  over- 
depression  of  either  end,  casters  are  attached  to  the  four  legs  of  the  appa- 
ratus, so  that  passing  backward  or  forward  with  either  front  or  rear  end 
depressed,  an  additional  pair  of  wheels  is  provided,  thus  facilitating  the 
progress  of  the  litter.  The  litter  frame  is  65  inches  in  length,  22  inches  in 
width  and  35  inches  in  height.  It  will  pass  through  a  28-inch  doorway. 

The  stretcher  resting  upon  the  litter  frame  is  composed  of  a  hollow  tube 
of  iron,  bent  into  an  oblong  form  and  provided  with  rounded  corners. 
Simple  cross-bars  of  flat  steel  form  the  bed  upon  which  the  blanket  or 
mattress  rests.  Four  wrought-iron  legs  are  provided,  that  the  stretcher 
may,  when  required,  be  used  independent  of  the  litter,  and  thus  rest  upon 
the  floor.  Its  length  is  76,  its  width  21,  and  when  used  separately  as  a 
stretcher,  its  height  is  5  ^  inches. 


TRANSPORTATION    OF    PATIENTS. 


The  Berlin  Wheel  Litter,  set  forth  in  figure  144,  is  one  of  the  most  elabo- 
rate patterns  of  wheel  litters  yet  placed  before  us.  It  consists  of  a  remov- 
able stretcher  resting  on  a  neat,  graceful  and  ornamental  carriage.  The 
stretcher  is  manufactured  from  seamless  steel  tubing  and,  while  its  bed  is 
composed  of  metal  strips,  its  weight  is  but  thirty  pounds.  The  stretcher 
handles  are  hinged  that  they  may  be  folded  when  necessary  to  carry  the 
litter  in  a  small  elevator  cage.  The  strips  forming  the  bed  and  supporting 
the  blankets,  or  bedding,  can  be  removed  for  cleaning.  A  head  rest  is  pro- 


Figure  143.    German  Wheel  Litter. 


Figure  144.    Berlin  Wheel  Litter. 


vided,  that  may  be  adjusted  to  any  height  or  removed  entirely  when  not 
wanted.  The  frame  rests  on  two  24-inch  and  two  1 2-inch  rubber-tired 
wheels,  one  of  the  latter  supporting  the  front  and  one  the  rear  end  of  the  lit- 
ter frame.  These  smaller  wheels  are  swiveled,  that  they  may  move  in 
any  direction,  thus  permitting  the  litter  to  be  turned  in  a  small  or  limited 
space.  The  length  of  stretcher,  with  handles  extended,  is  83  inches ;  with 
handles  folded,  63  inches;  length  of  carriage.  46^  inches;  height,  34 
inches,  and  extreme  width,  27^  inches. 

Hand  Stretchers. 

Hand  stretchers  are  narrow  cots  or  litters  composed  of  two  poles  united 
and  maintained  parallel  and  apart  by  transverse  bars  and  provided  with 
canvas  or  other  suitable  material,  so  fastened  to  and  stretched  from  one 
pole  to  the  other  as  to  form  a  couch.  They  are  of  two  forms :  Solid  and 
folding. 


Figure  145.    Solid  All-Metal  Stretcher. 

The  Solid  All-Metal  Stretcher,  displayed  in  figure  145,  is  particularly 
intended  for  hospital  use,  where  compactness  is  not  essential.  The  poles, 
cross-bars  and  legs  are  tubular,  thus  securing  the  greatest  amount  of 
strength  consistent  with  cost  and  weight.  The  slats  forming  the  bed  or 
support  are  of  thin  material,  carefully  fastened  to  the  side  and  end  bars. 
The  head  rest  is  adjustable  to  any  height,  or  may  be  lowered  so  that  it 
lies  level  with  the  bed.  The  iron  work  may  be  either  white  enamel  or 
black  japanned.  The  length  is  84,  width  23,  and  height  10  inches. 


HAND    STRETCHERS. 


87 


The  Plain  Folding  Stretcher,  outlined  in  figure  146,  is  one  of  the  cheapest 
patterns  in  the  market.  The  poles,  or  side -bars,  are  of  hard  wood,  cut 
square,  excepting-  at  the  extremities,  where  they  are  rounded  for  handles. 
The  transverse  bars  are  of  iron,  jointed  to  admit  of  folding,  and  provided 
with  a  stop  lock  so  that,  when  in  use,  there  is  no  danger  of  accidental  closing. 


Figure  146.    Plain  Folding  Stretcher. 


The  legs  are  also  of  hard  wood,  constructed  to  fold  up  when  the  stretcher  is 
made  ready  for  transportation.  The  canvas  is  stretched  tightly  from  pole 
to  pole,  to  give  firmness  and  rigidity  to  the  bed.  Its  width  is  23,  length  of 
canvas  72,  with  a  total  handle  length  of  92  inches.  Adjustable  slings,  the 
same  as  those  provided  with  the  U.  S.  A.  pattern,  shown  in  figure  2217,  can 
be  procured  if  desired. 


CHAPTER  IV. 


EQUIPMENT  OF  HOSPITAL. 

The  question  of  the  furniture  best  adapted  for  use  in  private  rooms  and 
wards  of  hospitals  is  one  in  which  plainness  and  simplicity  are  of  greater 
importance  than  beauty  of  design  or  elegance  of  finish.  While  this  may 
lead  to  complaints  from  patients  regarding  the  barrenness  of  their  quarters 
and  seeming  want  of  comfort,  yet  extreme  cleanliness  and  a  knowledge  of 
the  requirements  of  aseptic  surgical  treatment,  demand  that  the  furnish- 
ings of  rooms  for  patients  comprise  the  least  possible  number  of  pieces, 
simple  in  design,  and  so  arranged  that  they  may  be  easily  cleaned  in  all 
their  parts.  Primarily,  walls,  floors,  doors,  mouldings  and  casings  should 
be  so  constructed  and  of  such  material  that  they  may  be  thoroughly  cleansed 
with  soap  and  water,  and  when  necessary  with  antiseptic  solutions.  Cur- 
tains should  be  of  washable  material,  and  rugs  (where  permitted)  of  some 
fabric  that  may  be  sterilized  by  boiling  or  steaming. 


Figure  147.     Portable  Hospital  Bath. 


Figure  148.    Improved  Bellamy' 


Every  hospital  ward,  and  indeed  every  suite  of  operating  apartments, 
should  contain  ample  facilities  for  the  bathing  of  patients.  This  is  an 
important  factor  and  one  that  should  receive  most  careful  attention.  A 
high  degree  of  auto-cleanliness  should  be  secured  on  the  part  of  the  patient 
wherever  possible,  and  when  the  patient  is  unwilling,  he  should  be  placed 
in  the  hands  of  competent  assistants,  who  will  insist  in  carrying  out  the 
rules  and  details  laid  down  by  the  surgeon. 

Portable  Baths. 

Portable  baths,  if  not  a  necessity,  are  a  convenience,  and  one  or  more 
should  form  a  part  of  the  equipment  of  every  hospital.  They  may  be  util- 
ized in  cases  where  patients  are  unable  to  assist  themselves,  or  where  it  is 
desired  to  secure  immersion  in  cases  of  typhoid  fever,  burns,  etc.  Folding 
baths  will  be  found  described  in  a  chapter  devoted  to  the  resolution  of 
inflammation,  where  they  are  included  among  appliances  for  the  applica- 
tion and  extraction  of  heat. 

A  Portable  Bath  of  a  desirable  pattern  is  shown  by  figure  147.  It  con- 
sists of  a  steel  tub  mounted  on  solid  trucks  with  rubber-tired  wheels,  and 
provided  with  a  tongue  by  means  of  which  it  may  be  moved  about  as  re- 
quired. They  are  usually  26  inches  in  outside  width,  20  inches  in  depth, 


FURNITURE. 


89 


and  vary  in  length  from  4  to  5*4  feet,  while  the  projecting  rim,  shown  in 
the  illustration,  is  usually  of  polished  oak.  We  would  suggest  that  metal 
be  used  instead. 

Bellamy's  Bath,  as  manifest  in  figure  148,  while  it  may  be  employed  in 
the  general  treatment  of  inflammation,  is  particularly  designed  for  use  in 
cases  of  typhoid  fever.  It  consists  of  a  sheet  steel  tub,  a  trifle  over  six  feet 
in  length  and  of  suitable  width  and  depth  for  the  immersion  of  the  entire 
body  of  the  patient.  The  ends  are  firmly  stayed  by  braces,  while  lateral 
bars  furnish  a  strong  support.  A  steel  mattress,  swung  with  chains  and 
pulleys,  is  provided,  by  means  of  which  the  patient  may  be  so  raised  or 
lowered  so  that  any  degree  of  immersion  may  be  secured.  The  bath  is 
mounted  on  suitable  wheels  and  is  provided  with  an  outlet  valve,  by  means 
of  which  it  may  be  emptied.  It  forms  a  desirable,  portable  bath,  and  can  be 
employed  in  various  forms  of  treatment. 

The  Furniture  for  Each  Patient  may  consist  of  a  bed,  screen,  bedside 
stand,  chair,  wash-stand,  towel  rack,  wash-bowl,  pitcher,  slop  jar,  bed  pan, 
etc.  To  these  may  be  added,  in  special  cases,  articles  that  contribute  to  the 
comfort  of  patients,  particularly  during  the  latter  stages  of  convalescence, 
such  as  an  adjustable  table,  bed  tray,  head  rest,  etc. 

Beds. 

The  various  parts  that  form  a  bed  or  cot  should  be  so  constructed  as 
regards  design  and  material  as  to  admit  of  thorough  sterilization.  Bed- 
steads that  meet  all  requirements  may  be  procured  from  almost  any  furni- 
ture establishment. 


•     TTP^ 

•  i  r  '  t  ?  i  * 

^m 

;• 

.'; 

|J^-*^J                   »      |^«^ 

>*                 N^J! 

Figure  149.     Plain  Screen. 


Figure  149A.     Improved  Screen. 


The  only  problem  that  still  remains  unsolved  is  the  construction  of  com- 
fortable aseptible  springs.  At  the  present  writing,  the  ordinary  woven 
wire  spring  is  in  almost  universal  use,  and  hospital  managements  generally 
are  awaiting  a  design  capable  of  being  sterilized  without  injury  to  its  parts. 

Bedding. 

With  the  exception  of  the  mattress,  no  bedding  should  be  utilized  for 
patients  excepting  such  as  can  be  readily  washed  and  sterilized.  The  best 
filling  for  a  mattress  is  horsehair,  and  this  should  be  employed  where  pos- 
sible. Sheets  and  pillow  cases  are  much  better  when  manufactured  from 
linen,  but  if  the  expense  be  found  too  great,  ordinary  muslin  may  be  used 
instead. 


90 


EQUIPMENT    OF    HOSPITAL. 


Screens. 

These  usually  consist  of  some  form  of  a  movable,  usually  folding,  par. 
tition,  by  means  of  which  a  bed,  operating  table,  or  patient,  may  be  wholly 
or  partially  enclosed  from  view.  They  are  constructed  of  either  wood 
or  iron,  the  latter  being  preferable. 

The  Improved  Screen,  as  sketched  in  figure  149 A,  consists  of  an  upright 
frame  5  feet  in  length  and  height,  and  supported  at  each  end  by  a  small 
2 -wheel  truck,  the  length  of  the  axle  being  sufficient  to  insure  a  reason- 
able degree  of  steadiness.  Swinging  arms,  5  feet  in  length,  are  attached 
to  each  end  of  the  screen.  These  enable  the  operator  to  lengthen  the  appa- 
ratus from  5  to  15  feet  and  to  swing  the  arms  at  any  desired  angle. 

The  Plain  Screen,  exhibited  in  figure  149,  may  be  procured  in  any  desired 
size.  They  are  usually  90  by  96  inches. 

Bedside  Standa 

Small  tables,  or  stands,  upon  which  to  place  medicines,  dressings,  books, 
flowers,  etc.,  are  desirable  at  every  bedside.  The  requirements  of  such  a 
piece  of  furniture  are  such  that  plainness  and  simplicity  may  be  sought  in 
the  selection  of  a  suitable  design.  Plain  wooden  stands  will  answer  the 
purpose  where  the  expense  of  metal  cannot  be  incurred. 


Figure  150.    Ward  Stand,  with  Drawer. 


Figure  151.    Ward  Stand,  with  Chamber  Closet. 


The  Ward  Stand,  depicted  in  figure  150,  is  constructed  of  wrought  iron 
with  glass  top  and  two  metal  shelves,  the  whole  surmounted  by  a  neat  iron 
guard  rail  to  prevent  articles  placed  on  the  top  from  sliding  off.  It  is  pro- 
vided with  a  sheet-iron  drawer,  closely  fitted  to  the  imder  side  of  a  special 
sheet-iron  plate  underneath  the  glass.  The  size  of  the  top  is  14x15^  inches 
and  the  stand  is  33  inches  in  height. 

The  Ward  Stand  with  Chamber  Closet,  sketched  in  figure  151,  is  of  angle 
iron  with  glass  top  and  shelf,  the  former  protected  with  a  projecting  rail 
extending  along  both  sides  and  back.  A  closet  tightly  built,  and  enclosed 
by  a  swinging  iron  door,  is  located  directly  under  trie  shelf.  The  top  is 
16x18  inches  and  rests  on  an  angle  iron  base.  This  stand  is  provided  with 
casters. 


FURNITURE. 


91 


Chairs. 

While  ordinary  household  chairs  will  answer  fairly  well  for  use  in  wards 
and  the  apartments  of  patients,  strict  antiseptic  precautions  may  require 
the  use  of  patterns  constructed  entirely  of  iron,  that  they  may  be  thor- 
oughly sterilized.  This  is  particularly  true  in  wards  and  rooms  where 
patients  suffering  from  contagious  diseases  are  admitted.  Suitable  chairs 
fulfilling  these  requirements  may  be  obtained  in  various  patterns. 


Figure  153.     Hospital  Chair. 


Figure  153.    Andrews'  Hospital  Chair. 


The  Hospital  Chair,  the  construction  of  which  is  explained  by  figure  152, 
is  of  wrought  iron  with  either  a  perforated  wood  or  an  iron  bottom.  As 
here  exhibited,  it  forms  a  strong  and  efficient  pattern.  The  leg  bottoms  are 
supplied  with  rubber  crutch  tips  to  prevent  the  chair  from  slipping  and  to 
render  its  movements  noiseless. 

Andrews'  Hospital  Chair,  as  displayed  in  figure  153,  is  of  wrought  iron, 
and  each  part  consists  of  two  rods  twisted  together.  The  chair  is  of  strong 
and  neat  construction  and  may  be  obtained  with  either  lacquer  or  white 
enamel  finish. 

Wash- Stands. 

These  are  a  necessary  accompaniment  to  almost  every  hospital  bed,  par- 
ticularly those  occupied  by  patients  who  are  partially  able  to  assist  them- 
selves. While  ordinary  wood  stands  may  be  preferred,  on  account  of  the 
difference  in  price,  yet  it  is  advised  that,  where  possible,  none  but  asep- 
tible  iron  ware  be  procured.  The  latter  may  be  obtained  in  a  great  variety 
of  forms  and  patterns,  some  of  which  will  be  found  quite  ornamental. 

The  Plain  Wash-Stand,  exhibited  in  figure  154,  is  constructed  with  three 
curved  posts  or  uprights  so  shaped  as  to  support  in  their  centers,  a  pitcher, 
soap-dish  and  basin.  It  may  be  procured  with  or  without  rubber-tipped 
legs.  The  height  is  usually  about  32  inches. 

The  Wash-Stand  and  Tank,  shown  in  figure  155,  is  of  angle  iron  with  flat, 
depressed  top,  in  the  center  of  which  an  opening  is  provided  for  an  enamel 
ware  bowl.  A  shelf  underneath  forms  a  resting-place  for  a  slop  jar.  A 
removable  tank  with  faucet  rests  on  top  of  the  stand,  and  on  the  sides  of  the 
latter,  a  towel  rack  and  soap  box  are  conveniently  placed.  The  whole  forms 
a  desirable  pattern. 


92 


EQUIPMENT    OF    HOSPITAL. 


Towel  Backs. 

These  are  intended  not  only  for  use  in  holding  towels,  but  may  also  be 
employed  to  hold  dressings,  sheets,  etc. 

The  Towel  Rack  illustrated  by  figure  156  is  of  strong  construction,  and 
calculated  to  hold  the  greatest  number  of  pieces  in  a  given  amount  of  space. 
It  is  33  inches  in  height  and  24  in  width. 


Figure  154.    Plain  Wash-Stand. 


Figure  155.    Wash-Stand  and  Tank. 


The  Towel  Rack  portrayed  in  figure  157  is  of  more  simple  construc- 
tion and  is  adapted  for  use  where  only  a  limited  number  of  pieces  are  to  be 
suspended. 

Bedside  Utensils. 

Granite  iron  ware  or  similar  glazed  bedside  utensils  should  be  generally 
employed  for  hospital  use,  particularly  such  articles  as  are  directly  or  indi- 


TRUAX  GREENE  8  CO. 


Figure  150.    Towel  Rack. 


Figure  157.    Towel  Rack. 


rectly  brought  into  contact  with  patients.  To  .avoid  the  dangers  of  infec- 
tion, no  utensils  should  be  used  excepting  those  that  can  be  readily  cleaned 
and  sterilized. 


BEDSIDE    UTENSILS. 


93 


We  insert  descriptions  of  these  articles  more  with  a  view  of  furnishing 
the  information  by  which  these  articles  may  be  ordered,  than  of  making 
suggestions  on  a  subject  already  thoroughly  understood  and  appreciated. 

The  utensils  necessary  to,  or  occasionally  required  by  patients  are  wash- 
bowls, pitchers,  slop  buckets,  slop  jars,  chambers,  commodes,  cuspidors, 
spit  cups,  bed  pans,  etc.,  all  of  which  may  be  purchased  in  some  form  of 
glazed  ware. 


Figure  159.    Enamel  Water 
Pitcher. 


Figure  160.    Enamel  Slop 
Bucket. 


Figure  161.    Enamel 
Commode. 


The  Water  Pitcher,  outlined  in  figure  159,  shows  the  ordinary  form  in 
common  use.  They  may  be  procured  of  2,  3  or  4-quart  capacity. 

The  Slop  Bucket,  described  by  figure  160,  is  a  plain  pattern  with  cover. 
They  may  be  obtained  of  3  or  4-gallon  capacity. 

The  Commode,  illustrated  by  figure  161,  is  usually  io#  inches  high,  and 
8^  inches  in  diameter.  A  child's  size,  6^  inches  high  by  4%  inches  in 
diameter,  may  also  be  obtained. 


Figure.lf>i.J.    Enamel 
Wash  Basin. 


Figure  163.     Enamel 
Chamber. 


Figure  164.    Enamel     Figure  165.  Enamel 
Cuspidor.  Spit  Cup. 


The  Wash  Basin,  as  indicated  in  figure  162,  may  be  purchased  in  the 
following  sizes,  the  measurements  given  being  for  the  diameters,  outside 
measurement:  9^,  10^,  n/^,  12^,  13,  14  and  15  inches,  with  or  without 
rings,  the  1 4-inch  size  being  the  one  usually  preferred. 

The  Chamber,  drawn  in  figure  163,  should  be  provided  with  handle 
and  cover.  They  maybe  procured  of  the  following  diameters:  7^3,  8^, 
9^  and  n  inches. 

The  Cuspidor,  shown  in  figure  1 64,  is  one  of  the  better  patterns.  They 
may  be  procured  in  a  great  variety  of  forms.  Usually  they  are  about  5^ 
inches  high  by  7^  inches  in  diameter,  although  other  sizes  can  be  obtained. 

Spit  Cups,  as  exhibited  in  figure  165,  may  be  procured  with  or  without 
covers,  the  former  being  usually  preferred.  The  regular  size  is  4^  by  3^ 
inches. 

Drakeley's  Bed  Pan,  as  delineated  in  figure  166,  consists  of  a  soft  rub- 
ber invalid  ring,  in  the  center  of  which  a  metal  basin  is  firmly  secured  by 


94  EQUIPMENT    OF    HOSPITAL. 

means  of  a  double  flange.  This  basin  is  provided  with  an  outlet  of  suffi- 
cient size  to  allow  the  free  passage  of  all  fluid  discharges.  An  extra  pan, 
shown  in  the  illustration,  is  used  to  receive  fecal  discharges,  and  after  use 
this  inside  pan,  with  its  contents,  may  easily  be  removed  and  the  pan 
cleaned.  This  latter  feature  particularly  adapts  this  pattern  to  hospital 
use,  for,  excepting  in  cases  where  there  is  danger  of  infection,  nothing  but 


Figure  166.    Drakeley's  Bed  Pan. 

the  inside  pan  requires  cleansing.  The  soft  rubber  cushion  affords  a  com- 
fortable support  for  the  patient,  and  all  danger  of  soiling  the  bedding  or 
clothing  is  avoided.  This  is  an  excellent  apparatus  for  use  with  a  douche, 
and  for  this  purpose  a  metal  reservoir  often  accompanies  it. 

Rubber  Bed  Pans  are  of  two  varieties,  round  and  oval.  The  former  is 
the  ordinary  bed  pan,  figure  167,  so  commonly  in  use  that  it  requires  no 
further  description.  They  may  be  procured  with  or  without  outlet  tubes. 

The  Soft  Rubber  Oval  Bed  Pan,  manifest  in  figure  168,  may  also  be  pro- 
cured with  or  without  an  outlet  tube.  These  varieties  are  all  inflated  by 
means  of  suitable  tubes  and  valves,  and  as  they  are  soft  and  yielding,  they 
are  preferred  by  many  patients. 


Figure  167.     Soft  Rubber  Round  Bed  Pan, 
with  Outlet  Pipe. 


Figure  168.    Soft  Rubber  Oval  Bed  Pan, 
with  Outlet  Pipe. 


Earthen  Bed  Pans  are  of  two  patterns;  the  old-fashioned  and  long-used 
variety  shown  by  figure  167 A,  and  a  later  improved  one,  known  as  the 
Eureka,  and  illustrated  by  figure  i68A.  This  latter  differs  from  those  in 
ordinary  use  in  being  smaller  and,  therefore,  much  more  easily  adjusted. 
Its  capacity  is,  however,  equal  to,  if  not  greater  than,  the  old  style  pattern. 
Its  peculiar  form  renders  it  easier  to  properly  adjust  it  beneath  a  heavy 
patient.  As  it  is  open  at  the  top,  it  can  be  easily  cleaned. 


FURNITURE. 


95 


Enamel  Bed  Pans  may  be  secured  of  two  patterns ;  one  the  old-fashioned 
oval  pattern,  depicted  in  figure  169,  the  other  an  oblong  variety,  the  top  of 
which  is  partially  covered  with  a  metal  plate  that  forms  a  portion  of  "the 


Figure  1C" A.    Earthen  Bed  Pan. 


Figure  108A.     Eureka  Bed  Pan. 


instrument.      This    is   well    shown  in  figure  170  and  requires  no  further 
description  here.     The  size  of  the  latter  is  15^  by  n^  by  3  inches. 

Bedside  Tables. 

These  may  be  utilized  in  promoting  and  furthering  the  comfort  of 
patients,  particularly  during  convalescence.  They  usually  consist  of  some 
form  of  stand  or  table,  the  top  of  which  is  securely  fastened  to  an  arm  that 
may  be  projected  over  the  bed  and  in  front  of  the  patient. 

Baker's  Bedside  Table,  as  is  apparent  in  figure  171,  forms  a  neat  and  in- 
expensive pattern,  manufactured  from  hollow  wrought  iron.  It  is  both 
light  and  strong.  As  it  has  an  adjustable  top,  it  may  not  only  be  raised  or 
lowered  to  accommodate  the  height  of  the  bed,  but  may  also  be  either  fixed 


Figure  169.    Enamel  Bed  Pan. 


Figure  170.    Enamel  Oblong  Bed  Pan. 


in  a  horizontal  position  or  turned  at  an  angle.  It  may  be  used  as  an  eat- 
ing, reading  or  work  table,  and  as  such,  if  placed  in  every  hospital,  would 
be  in  great  demand  among  patients 

Back  Rests. 

These  are  constructed  for  the  purpose  of  relieving  patients  who  are  com- 
pelled to  remain  in  bed  for  long  periods.  By  means  of  them  patients  may 
be  placed  in  a  reclining  or  sitting  posture,  thus,  in  many  cases,  affording 
relief  by  change  of  position. 

The  Back  Rest  represented  in  figure  173  consists  of  a  wood  or  iron  frame 
that  may  be  covered  with  canvas  or  such  other  cloth  as  is  desired.  It  is 
supplied  with  a  ratchet  and  proper  braces,  and  can  be  adjusted  to  any 
height,  or  may  be  closely  folded. 

The  Back  Rest  detailed  in  figure  172  represents  a  similar  form,  but  pro- 
vided with  arm  rests  and  guards.  The  latter  serve  to  prevent  a  patient 
from  slipping  or  sliding  off  should  he  fall  asleep  while  resting  on  the  appara- 
tus. Either  of  the  styles  above  shown  may  be  used  with  or  without 
pillows. 

Bed  Trays. 

These  are  intended  to  take  the  place  of  bedside  tables.  They  differ  from 
the  latter  in  that  when  in  use  they  rest  upon  the  bed  as  an  ordinary  table 


96 


EQUIPMENT    OF    HOSPITAL. 


stands  upon  the  floor.     They  are  intended  principally  for  eating  tables, 
but  may  be  made  to  answer  many  other  purposes. 


Figure  171.    Baker's  Bedside  Table. 


Figure  172.     Back  Rest,  with  Arms. 

The  Folding  Bed  Tray,  as  portrayed  in  figure  174,  may  be  procured  in 
various  woods  and  of  different  sizes.  As  they  fold  into  small  compass 
when  not  in  use,  they  are  convenient  for  storage  or  transportation.  As 
they  are  made  of  wood,  they  are  not  so  durable  as  the  heavier  and  stronger 


Figure  173.    Plain  Back  Rest. 


Figure  174.    Folding  Bed  Tray. 

iron  bedside  tables  previously  described.  The  tray  is  so  arranged  that  it 
can  be  carried  by  an  attendant  to.  the  kitchen  or  dining-room,  a  meal 
placed  upon  it  ready  for  serving,  after  which  the  filled  tray  may  be  con- 
veyed to  the  patient  and  placed  in  position  by  simply  unfolding  the  legs. 


CHAPTER  V. 


OPERATING   APARTMENTS   AND   EQUIP- 
MENT. 

The  location,  construction  and  furnishing  of  the  rooms  necessary  for  sur- 
gical operating  purposes  is  a  subject  that  should  receive  most  careful  con- 
sideration, for  on  this  the  success  or  failure  of  a  certain  percentage  of  cases 
may  depend.  The  demands  for  a  perfect  surgical  technique  are  exacting, 
and  only  after  a  proper  understanding  of  these  requirements  can  one  be  en- 
abled to  produce  plans  and  specifications  that  fulfill  every  indication. 

In  the  preparation  of  plans  for  a  hospital  to  include  operating  apart- 
ments, it  is  advised  that  they  be,  so  far  as  possible,  isolated  from  the  bal- 
ance of  the  building  in  such  a  manner  that  while  they  are  easy  of  access 
from  the  various  floors  and  wards,  neither  the  surgeon  and  his  staff  nor  the 
inmates  of  the  hospital  will  be  annoyed  one  by  the  other.  The  surgeon 
and  his  assistants  require  plenty  of  fresh  air  and  ventilation,  abundance 
of  light,  quiet  surroundings,  and  more  space  than  is  usually  allotted  for 
such  purposes.  The  operating-room  should  be  so  located  that  noises  and 
sounds  emanating  from  it.  will  not  disturb  or  annoy  general  patients,  nor 
should  the  vapors  of  ether  or  other  anesthetics  be  permitted  to  enter  or  cir- 
culate through  the  wards  or  rooms  of  the  hospital.  All  this  can  best  be 
secured  on  the  top  floor  of  the  building,  for  there  every  condition  appears 
to  be  most  favorable. 

Suitable  apartments  may  consist  of  one  large  room  for  operating  and  at 
least  three  or  four  smaller  ones;  one  for  the  storage  and  care  of  surgical 
instruments;  a  second  as  a  dressing,  ^disinfecting  and  bath  room  for  the  sur- 
geon and  his  assistants ;  a  third  for  the  preparation  and  anesthetizing  of  the 
patient,  and  a  fourth  as  a  general  reception  room  for  those  awaiting  oper- 
ation. Many  surgeons  prefer  to  use  the  latter  room  for  the  retention  of 
patients  after  operation,  so  that  they  may,  in  a  measure,  recover  from  its 
effects  before  being  returned  to  their  apartments. 

In  addition  to  these,  a  water-closet  and  general  wash-room  should  be 
supplied.  These,  however,  should  be  connected  with  one  of  the  smaller 
apartments,  that  at  least  one  or  more  rooms  may  intervene  between  them 
and  the  surgical  room. 

The  important  element  in  the  construction  of  operating  apartments 
should  be  the  designing  of  plans  that  will  enable  the  attendants  to  easily 
secure  the  highest  possible  degree  of  surgical  cleanliness.  No  matter  what 
minor  defects  in  the  general  plans  are  yielded  to  from  necessity,  this  one 
specification  should  be  insisted  upon  in  each  instance.  Every  feature  that 
will  tend  to  prevent  the  accumulation  of  dirt  and  dust,  and  every  arrange- 
ment in  the  construction  that  will  aid  in  securing  a  higher  degree  of  surgical 
cleanliness,  should  be  adopted.  All  corners  should  be  well  rounded.  This 
is  not  only  true  of  the  angles  in  the  room,  but  of  the  junctions  of  the  side 
walls  with  ceiling  and  floor.  The  floor  should  be  .water-tight,  of  tiling 
carefully  and  closely  laid,  or  of  cement,  smooth  and  highly  polished.  Hard 

7  97 


98  OPERATING    APARTMENTS    AND    EQUIPMENT. 

wood  may  be  used  if  closely  joined  aifd  well  polished,  though  it  is  inferior 
to  either  tile  or  cement.  While  many  authorities  advocate  the  employment 
of  marble  in  the  operating-room,  we  do  not  believe  it  a  suitable  substance 
either  for  the  construction  of  floor,  walls,  sinks,  or  other  similar  purposes. 
As  is  well  known,  it  is  porous  to  a  considerable  degree.  Fats,  blood 
and  other  material  likely  to  be  or  to  become  infected,  are  absorbed  to  a 
greater  or  lesser  extent,  and  while  the  crystalline  structure  of  the  marble 
might  not  permit  of  extensive  growths  of  pathogenic  bacteria,  yet  there 
seems  to  be  no  question  that,  in  a  limited  way,  this  substance  may  become 
and  remain  infected. 

Side  walls  to  a  height  of  from  four  to  six  feet  may  be  of  the  same  mate- 
rial as  the  floor.  Tile  answers  an  admirable  purpose.  Crystopal,  a  glass 
preparation,  is  being  largely  used  and  seems  to  possess  every  qualification. 
It  is  less  expensive  than  tile,  and  as  it  may  be  obtained  in  various  colors 
and  shapes,  it  is  quite  desirable.  It  is  strong  enough  for  every  purpose 
and  is  not  affected  by  germicidal  fluids,  hot  water,  steam,  or  other  disin- 
fecting methods. 

These  principles  of  construction  should  be  applied  not  only  to  the  oper- 
ating-room but  to  the  smaller  rooms  as  well,  for  infectious  matter  may  be 
indirectly  conveyed  from  any  one  of  the  adjacent  apartments  to  the  main 
or  surgical  room. 

Natural  light  will  be  best  if  admitted  from  one  or  two  sides  and  the  ceil- 
ing, and,  when  possible,  a  north  exposure  should  be  secured.  All  skylights, 
if  likely  to  be  pierced  directly  by  the  sun's  rays,  should  be  of  ground  glass, 
and  shades,  if  used,  should  be  removable  and  "spread"  instead  of  rolled. 

The  introduction  of  luminous  prisms  will,  no  doubt,  prove  of  advan- 
tage in  the  lighting  of  operating-rooms.  Acting  on  the  well  known  prin- 
ciple that  light,  passing  from  one  transparent  medium,  such  as  glass  or  water, 
to  another,  undergoes  a  change  of  direction  at  the  surface  of  separation, 
these  ingenious  devices  have  been  made  to  light  spaces  by  this  refrac- 
tion heretofore  too  dark  for  operating  purposes.  By  their  use  natural  light, 
even  from  a  distant  window,  may  frequently  be  diverted  to  any  portion  of 
the  building  without  any  apparent  loss  to  parts  previously  lighted.  These 
lenses  are  so  constructed  that  diffused  light  may  be  thrown  or  concentrated 
upon  any  desired  spot.  For  instance,  an  operating  table  placed  in  the 
arena  of  a  large  amphitheater  may  be  brilliantly  lighted  from  windows  sur- 
rounding the  amphitheater  and  far  above  the  space  to  be  lighted.  It  is  not 
claimed  that  additional  light  is  created,  but  that  it  may  be  either  uniformly 
diffused  or  concentrated  at  any  given  point.  It  would  seem  that  in  the 
lighting  of  operating-rooms  in  the  future,  these  prisms  can  be  made  to 
serve  an  admirable  piirpose. 

Good 'ventilation  is  essential.  Pure  air  should  be  forced  into  the  room 
at  such  points  and  in  such  directions  as  will  avoid  drafts  across  the  oper- 
ating table.  The  ventilating  fan  should  be  of  a  separable  pattern,  that  it 
be  easily  cleaned.  If  the  air  be  forced  through  layers  of  plain  cotton, 
the  latter  held  in  place  by  fine  wire  gauze,  it  may  be  filtered,  and  the  en- 
trance of  much  foreign  matter  prevented.  Noiseless  sliding  doors  are  to 
be  preferred,  but  if  hinged  doors  are  employed,  they  would  better  open 
outward,  as  this  will  serve  to  economize  space  in  the  interior  of  the  room. 
It  has  been  advised  that  the  doors  to  an  operating-room  should  have  double 
swing,  as  they  can  thus  be  opened  by  foot  or  knee  pressure  from  either 
direction. 

Door  and  window  frames  may  be  of  iron ;  in  fact,  the  best  results  can 


FURNITURE    AND    FIXTURES.  99 

be  obtained  only  if  the  whole  interior  surface  of  the  room,  as  well  as  the 
fixtures  and  furniture,  be  composed  of  material  that  will  admit  of  sterili- 
zation or  cleansing  with  hot  water. 

Pipes  for  heating  purposes  should  be  placed  underneath  the  floor,  and 
suitable  radiators  may  be  located  in  adjoining  rooms.  No  pipes  or  radia- 
tors should  be  situated  in  the  operating-room,  as  all  the  heat  required  should 
enter  the  room  by  radiation  from  without. 

The  furnishing  of  the  operating  apartments  is  a  subject  the  importance 
of  which  should  not  be  under-estimated.  The  fixtures  and  furniture  can 
serve  the  best  interests  of  the  surgical  staff  only  when  of  the  most  approved 


Figure  175.    Showing:  Railing  in  St.  Joseph's  Hospital,  Chicago. 

construction.  Surgical  technique  can  not  be  perfect  unless  the  surgeon  be 
supplied  with  an  armamentarium  in  keeping  with  the  requirements  of  the 
latest  improved  methods  in  surgical  practice. 

In  the  manufacture  of  furniture  intended  for  surgical  uses,  all  sub- 
stances should  be  excluded  excepting  metal,  glass,  rubber,  porcelain,  and 
similar  impermeable  substances,  together  with  such  woven  fabrics  as  can 
be  readily  sterilized  by  steam  or  boiling  water.  Everything  should  present 
an  appearance  of  immaculate  cleanliness,  and  should  admit  of  easy  cleansing 
with  soap,  water,  scrubbing  brush  and,  where  necessary,  chemical  solu- 
tions, or  live  steam. 


100 


OPERATING    APARTMENTS    AND    EQUIPMENT. 


All  furniture  and  fixtures  should  be  washed  and  cleansed  daily,  particu- 
larly after  having  been  in  use,  and  every  possible  precaution  should  be 
taken  to  secure  and  maintain  a  condition  of  absolute  surgical  cleanliness. 

An  abundance  of  artificial  as  well  as  natural  light  is  necessary.  The 
former  will  be  best  supplied  by  an  incandescent  system,  for  not  only  does 
the  light  thus  generated  approach  more  closely  to  that  of  the  sun's  rays, 
but  lamps  may  be  so  constructed  as  to  be  easily  moved  into  that  position 
which  will  best  serve  the  needs  of  the  surgeon.  An  incandescent  light  with 
a  McCreary  half  shade"  will  be  found  serviceable,  particularly  when  sus- 
pended by  wires  that  will  admit  of  its  being  freely  moved  from  place  to 
place,  as  required. 

If  shelves  form  a  part  of  the  fixtures  of  the  operating-room,  they  should 
be  of  plate  glass,  resting  on  brackets  and  removable.  A  fixed  shelf  usually 
forms  nooks  and  angles  difficult  to  sterilize.  Such  shelves  and  suitable 
brackets  can  be  secured  of  any  desired  size.  We  believe,  however,  that,  as 
a  rule,  it  would  be  better  if  the  operating-room  contained  no  shelves,  re- 
lying for  shelf  space  on  stands  and  tables,  articles  that  may  be  removed  for 
sterilization  or  washed  and  scrubbed  with  hot  soda  solutions. 


Figure  176.    Showing  Railing  in  Woman's  Hospital,  Chicago. 

In  operating-rooms  where  spectators  are  admitted,  railings  should  be 
provided,  so  that  in  their  zeal  and  anxiety  to  obtain  a  closer  view  of  an  oper- 
ation, visitors  may  not  encroach  upon  the  space  necessary  to  the  surgeon  and 
his  assistants,  nor  contaminate,  either  directly  or  indirectly,  the  exposed 
wound  tissues  by  too  close  proximity  to  the  field  of  operation  or  the  ap- 
pliances in  use.  Such  a  railing  should  be  strong  enough  to  sustain  the  lean- 
ing weight  of  several  persons.  Its  extent  and  location  must  be  suited  to 
the  room  and  its  conditions,  and  it  may  be  movable  or  immovable.  Figure 
175  illustrates  a  system  of  railings  in  use  at  St.  Joseph's  hospital,  Chicago. 
It  consists  of  a  heavy  framework  of  brass  tubes,  rods  and  standards,  so  ad- 


FURNITURE    AND    FIXTURES. 


101 


justed  that  each  part,  from  its  peculiar  shape,  forms  a  firm  support.  As 
the  space  inside  the  inclosure  may  be  diminished  or  enlarged  at  will, 
this  design  is  very  satisfactory. 

Figure  176  illustrates  a  fixed  form  of  railing  extending  across  one  end 
of  an  operating-room.  This  pattern  was  designed  for  the  Woman's  hospi- 
tal, Chicago.  It  is  made  of  tubular  iron,  supported  by  strong  cast  iron 
braces  or  uprights.  The  appliance  is  strongly  built,  will  withstand  heavy 
pressure,  and  constitutes  a  solid  and  stationary  fixture.  By  moving  the 
operating  table  into  the  small  circle  inclosed  by  the  central  portion  o.f  the 
rail,  spectators  may  obtain  a  sufficiently  close  view  to  enable  them  to  wit- 
ness all  the  details  of  the  surgical  technique. 

The  operating-room  should  be  supplied  with  ample  facilities  for  wash- 
ing the  hands  and  arms  of  the  surgeon  and  assistants,  and  for  this  purpose 


Figure  177.    Kelly's  Sink  and  Folding  Wash-bowl  Support. 

bowls  or  sinks  of  various  sizes  should  be  supplied,  one  or  more  of  which 
should  be  large  enough  to  admit  of  the  complete  immersion  of  the  hand 
and  forearm.  Such  receptacles  may  be  movable  or  stationary. 

The  best  appliance  of  this  kind  would  seem  to  be  a  long,  narrow,  and 
somewhat  shallow  sink,  or  a  series  of  smaller  sinks,  over  which  bowls  of 
proper  size  might  be  supported  in  suitable  frames,  these  bowls  located 
immediately  under  spigots.  These  spigots  should  connect  with  sterilized 
hot  and  cold  water  tanks  located  in  an  adjoining  room,  the  spigots  extending 
through  the  partition.  Such  an  arrangement  would  render  the  frequent 
changing  of  the  water  in  the  bowls  an  easy  matter,  for,  as  fast  as  might  be 
necessary,  the  bowls  could  be  overturned  and  the  contents  poured  into  the 
sink  below.  All  this  could  be  accomplished  without  contact  with  infected 
articles. 

That  the  surgeon  may  not  be  obliged  to  grasp  the  handle  of  the  spigot 
to  close  or  open  it,  several  attachments  have  been  devised  that  may  be 
operated  by  foot  pressure.  A  majority  of  these  inventions  necessitate 
more  or  less  parts  and  mechanism  in  the  operating-room,  and  we  would 
advise  that  the  pattern  of  Robb  be  employed,  as  in  his  device  only  the  end 
of  an  upright  pin  or  rod  is  placed  in  the  floor  of  the  operating-room,  while 


102  OPERATING    APARTMENTS    AND    EQUIPMENT. 

the  lever  faucet,  spring-,  bars,  etc. ,  are  located  under  the  floor  and  in  an 
adjoining  room  with  the  reservoirs.  By  this  construction  the  simplest  form 
is  secured.  In  the  absence  of  such  an  apparatus,  plain  spigots  or  faucets 
may  be  provided.  The  water  tanks  should  be  two  in  number  and  of  such 
size  as  will  secure  for  the  use  of  the  operators  all  the  water  that  may  be 
necessary;  in  fact,  so  far  as  their  needs  are  concerned,  the  supply  should 
be  unlimited.  This  water,  whether  hot  or  cold,  should  be  sterilized.  The 
nearly  obsolete  method  of  attempting  to  secure  an  aseptic  condition  of 
the  hands  and  arms  with  contaminated  water  should  be  absolutely  inter- 
dicted. If  sterilization  means  anything,  it  means  all  that  the  name  implies, 
and  in  carrying  out  the  necessary  requirements,  sterilized  water  is  as  essen- 
tial as  any  other  one  element  in  disinfection.  To  secure  sterile  water,  it  is 
necessary  only  to  boil  it,  and  some  apparatus  by  which  the  boiling  and 
storing  of  the  sterile  water  can  be  secured,  is  an  indispensable  part  of  the 
apparatus  of  every  suite  of  operating  apartments.  If  no  better  place  can 
be  secured,  the  water  may  be  boiled  and  stored  in  large  glass  bottles,  pre- 
viously sterilized  and  kept  exclusively  for  this  purpose. 

No  stoppers  should  be  employed  in  such  bottles  except  wads  or  rolls  of 
sterilized  non-absorbent  cotton. 

The  steam  and  hot  air  sterilizing  apparatus  should  be  located  in  an 
adjoining  room,  although,  when  space  is  limited,  they  may  form  a  portion 
of  the  furniture  of  the  operating-room.  It  would  be  better  not  to  include 
them  with  the  furniture  of  the  surgical  instrument  room,  because  the  con- 
stant escape  of  steam  would  have  a  tendency  to  produce  rusting  of  steel 
instruments. 

EQUIPMENT  OP  OPERATING  ROOM. 

The  saving  of  time  during  an  operation  is  of  great  importance.  An 
equipment  of  furniture  and  fixtures  should  be  selected  regardless  of 
expense  to  enable  the  surgeon  and  his  assistants  to  perform  a  given  num- 
ber of  operations  in  the  shortest  time.  Not  only  are  the  dangers  to  life 
thereby  lessened,  but  the  value  of  the  time  saved  to  the  surgeon  by  efficient 
apparatus  is  often  of  greater  value  to  him  in  a  single  day  than  the  entire 
cost  of  an  incomplete  and  poorly  selected  operating  armamentarium. 
Among  the  articles  of  furniture  forming  an  efficient  equipment,  none  is  of 
more  importance  than  the  operating  table.  This  must  be  suitable  to  the 
special  requirements  of  the  surgeon,  and  should  include  proper  cover, 
perineal  pads  and  one  or  more  forms  of  crutches,  or  leg  supports.  In  long 
and  tedious  operations,  a  stool,  adjusted  to  various  heights,  will  be  found 
of  service.  At  least  three  tables  or  stands  should  be  provided;  one  for 
dressings  and  other  similar  articles,  one  for  instruments  and  instrument 
trays,  and  a  third  for  ligatures,  needles,  etc. 

Surgical  instruments  can  be  properly  cared  for  only  when  stored  in  cases. 
While  they  form  a  part  of  an  operating-room  outfit,  they  should,  whenever 
possible,  be  located  in  an  adjoining  room.  In  connection  with  these  cases 
some  form  of  ward  carriage  is  almost  a  necessity,  for  it  occasionally  happens 
that  operations  are  necessary  in  some  room  other  than  that  generally  used 
for  operating  purposes. 

A   sink  with  wash-bowls  and  hot  and  cold  sterilized  water  should  be 
provided  in  or  near  the  operating-room,  and  one  or  more  portable  wash- 
stands  with  bowls,  to  which  the  surgeon  may  turn  and  cleanse  his  hands 
whenever  necessary,  should  be  convenient  to  the  operating  table. 
;  0    3  rJ  3  J  J  0  •) 
>  [/.  L  I  fi  f  Z.  7  H  ^ 


OPERATING    TABLES. 


103 


Means  for  sterilizing  instruments,  dressings,  garments,  etc.,  and  wheel 
litters  by  which  patients  may  be  conveyed  to  and  from  the  operating-room, 
are  also  necessary. 

Receptacles  for  septic  material,  fluids  and  solids  will  be  required.  Irri- 
gating apparatus  should  be  provided,  either  in  the  form  of  ordinary  bottles 
located  upon  shelves  or  high  stands,  or  suspended  bottles,  all  properly 
equipped  with  tubes,  cut-offs,  and  syringe  points. 


Plain  Operating  Table,  with  Glass  Top.        Figure  179.    Sonnenberg's  Operating  Table. 


A  number  of  trays  of  various  sizes  in  which  to  place  instruments,  liga- 
tures and  needles,  either  dry  or  immersed  in  fluids,  should  be  at  the  disposal 
af  the  surgeon  and  attendants.  In  addition  to  the  above-mentioned 
articles,  there  should  be  a  liberal  quantity  of  bottles,  boxes,  jars,  and  other 
utensils  in  which  to  place  ligatures,  dressings,  drainage  tubes,  syringes, 
and  similar  articles.  All  such  packages  should  be  of  glass  or  other  suitable 
material,  that  they  may  be  easily  sterilized  and  their  contents  maintained 
free  from  contamination. 

Every  operating-room  should  be  supplied  with  one  or  more  bed  pans,  a 
male  and  female  urinal,  and  a  supply  of  hot  water  bottles.  It  should  also 
include  as  a  part  of  its  permanent  equipment,  a  galvanic  and  faradic  battery. 

Operating  Tables. 

The  table  upon  which  the  patient  is  placed  while  being  examined  or 
surgically  treated,  is  called  an  operating  table.  Usually  these  are  made  in 
special  patterns  designed  to  facilitate  the  performance  or  carrying  out  by 
the  surgeon  of  particular  methods  of  procedure.  They  may  be  nothing 
more  elaborate  than  a  plain  deal  table  employed  when  operating  in  a  pri- 
vate residence,  or  one  extemporized  by  utilizing  a  door  or  a  board  or  two 
when  an  emergency  on  the  field  of  battle  or  at  a  railway  or  other  accident 
demands  prompt  surgical  interference. 

Operating  tables  may  be  procured  in  such  a  variety  of  forms  that  the 
surgeon  attempting  to  make  a  selection  often  finds  himself  in  a  state  of 
bewilderment  as  to  which  particular  pattern  offers  the  greatest  advantages. 
As  it  is  not  the  purpose  of  this  work  to  attempt  a  description  of  all  the 
appliances  in  any  one  department  of  surgery,  we  shall  limit  our  illustra- 
tions to  those  designs  which,  in  our  opinion,  possess  special  advantages 
either  in  pattern  or  price.  The  elements  necessary  in  an  operating  table 
must  depend  largely  on  the  requirements  of  the  individual  surgeon.  It 
should  be  remembered  that  movements  and  joints  are  inseparable  from 
complications,  and  that  the  more  "positions"  one  can  secure  in  a  table,  the 
more  complicated  it  must  be.  It  is  evident  that  the  less  the  number  of 
movable  parts,  the  more  easily  can  the  table  be  cleansed. 

Dudley  advises  that  tables  for  gynecological  purposes  be  constructed  so 


104 


OPERATING    APARTMENTS    AND    EQUIPMENT. 


that  the  surface  shall  slant  toward  the  foot  in  order  to  supply  good  drain- 
age and  that  the  difference  in  the  height  of  the  two  ends  be  about  4  inches. 
Plain  tables,  manufactured  from  either  wood  or  iron,  may  be  procured 
in  many  forms.  Because  of  their  simplicity  they  are  preferred  by  many 
operators. 


Figure  180.    Krug's  Trendelenberg  Frame. 

The  Plain  Operating  Table,  illustrated  by  figure  178,  is  of  iron  and  glass  in 
a  cheap  form  of  construction.  The  posts,  cross-bars  and  extension  bars 
are  of  hollow  wrought  iron,  with  braces  of  ordinary  fiat  bars.  The  top  is 
of  heavy  glass,  three-quarters  to  one  inch  thick,  24  inches  wide  and  66 
inches  long,  while  the  height  of  the  table  is  34  inches.  It  is  mounted  on 
castors  and  will  support  any  reasonable  weight. 

The  construction  of  this  table  is  such  that  it  may  be  sold  at  a  low  price, 
and  while  it  is  strong  and  durable,  the  joints  are  not  usually  as  closely 
fitted  as  more  expensive  designs. 


Figure  181.    Hamburg  Operating  Table. 

Sonnenberg's  Operating  Table,  as  shown  in  figure  179,  is  constructed  with 
double  side  bars  and  braced  in  all  directions.  Though  light  in  construc- 
tion, it  is  firm  and  steady  when  in  service.  As  it  is  manufactured  entirely 
of  wrought  iron,  the  joints  may  be  closely  and  accurately  fitted.  The  top  is 
of  heavy  glass,  one  inch  in  thickness,  21  inches  wide,  and  72  inches  long, 
while  the  height  of  the  table  is  34  inches.  Solid  castors  are  provided  of  suffi- 
cient strength  to  carry  any  required  weight.  As  the  table  is  constructed 
without  movable  joints  or  parts,  it  may  be  sterilized  without  difficulty. 
Being  covered  with  white  enamel,  it  may  be  washed  or  scrubbed  without 
danger  of  rusting.  The  glass  is  protected  from  fracture  by  resting  upon 
10  rubber  cushions  or  buttons,  thus  giving  elasticity  to  its  support. 

Trendelenberg  Frames  are  designed  for  use  with  tables  of  solid  top  construc- 
tion, when  it  is  desirable  to  place  patients  in  the  Trendelenberg  position. 


OPERATING    TABLES. 


105 


Krug's  Frame  for  securing-  the  Trendelenberg  posture,  as  exhibited  in 
figure  1 80,  is  one  of  the  most  useful  appliances  of  its  kind.  By  means  of  it 
a  flat  or  solid  top  table  may  quickly  be  converted  into  one  permitting  the 
elevation  of  the  extremities  necessary  in  the  position  of  Trendelenberg. 
Constructed  entirely  of  wrought  iron,  it  is  not  only  strong,  but  durable. 
Adjustable  to  any  height,  it  will  meet  every  indication  of  such  an  appara- 
tus. As  it  may  be  clamped  to  a  table,  it  can  be  secured  against  accidental 
displacement,  and  as  it  may  be  folded  into  small  space,  it  may  be  readily 
transported  from  place  to  place.  With  this  attachment  a  surgeon  may  con- 
vert an  ordinary  deal  table  into  one  that  will  furnish  him  this  now  much 
prized  position.  The  length  occupied  by  it  on  the  table  top  is  36  inches, 
while  its  width  is  19^  inches. 

The  Hamburg  Operating  Table  (Schede),  displayed  in  figure  1 8 1,  is  one  of 
the  strongest  of  its  class.  It  is  manufactured  of  heavy,  hollow  wrought 
iron  pipes,  and  is  provided  with  a  wide  base,  thus  ensuring  great  strength 
and  firmness.  Its  principal  feature  is  in  the  construction  of  the  table  top, 


Figure  182.     Baldwin's  Operating  Table  with  Top 
Extended. 


Figure  183.    Baldwin's  Operating  Table  with 
Head  Piece  Elevated. 


which  consists  of  two  heavy  plates  of  glass  resting  on  a  gutter-shaped 
frame  so  adjusted  that  the  inner  edges  of  the  glass  plates  are  each  two 
inches  lower  than  their  outer  edges  or  margins.  The  gutter  thus  formed 
is  intended  for  drainage,  and  to  ensure  this  without  danger  of  spilling  fluids 
upon  the  floor,  a  copper  trough  is  provided,  that  rests  immediately  below 
the  opening  between  the  two  glass  plates  referred  to,  and  extends  from  one 
end  of  the  table  to  the  other.  A  central  depression  in  the  trough  is  pro- 
vided with  an  outlet,  through  which  all  fluids  may  escape  into  a  bucket 
placed  beneath,  but  in  the  table  frame.  This  latter  adjustment  is  neces- 
sary, because  the  receptacle  for  such  fluids  should  move  with  the  table,  in 
order  that  no  displacement  of  the  slop  jar  may  occur.  The  extreme  width 
of  the  table  is  28,  its  length  66,  and  its  height  at  outer  border  37  inches. 

Baldwin's  Operating  Table,  as  pictured  in  figures  182  to  186  now  appears 
to  possess  more  advantages  for  general  work  than  any  previously  designed 
pattern.  Although  with  it  almost  any  desired  position  may  be  obtained, 
it  is  so  simple  in  its  construction  that  it  is  without  ratchet,  cog,  pinion 
or  chain.  It  possesses  all  the  advantages  of  the  Boldt,  Edebohl,  Cleveland 
and  similar  patterns  without  their  complicated  mechanism  In  addition 
to  all  this,  the  height  of  the  operating  field  is  not  increased  by  changing 
the  patient  from  a  horizontal  to  the  Trendelenberg  position,  as  displayed  in 
figure  1 84.  The  principal  feature  of  the  table  is  that  the  top  is  so  hinged 
that  with  a  patient  in  the  recumbent  position,  the  whole  is  so  evenly  bal- 


106 


OPERATING    APARTMENTS    AND     EQUIPMENT. 


anced  that  the  anesthetist  with  one  hand  and  with  little  effort  may  depress 
the  head  and  elevate  the  hips,  either  with  the  table  top  straight  or  in  the 
Trendelenberg  position. 

Any  degree  of  obliquity  may  be  maintained  by  means  of  two  slotted 
bars,  through  which  a  screw  rod  projects  with  such  an  adjustment  that  a 
slight  turn  of  the  rod  handle  will  lock  the  table  in  the  desired  position. 
The  main  portion  of  the  table  top  drains  to  the  center  into  a  receptacle 
placed  upon  a  sliding  plate  resting  in  the  table  frame.  That  portion  of  the 
top  upon  which  the  head  and  neck  of  the  patient  rest,  is  hinged  in  such  a 
manner  that  it  may  be  elevated  by  means  of  a  curved  upright,  so  that  the 
head  may  rest  in  a  horizontal  plane  when  the  table  top  is  inclined.  The 
foot-piece  is  arranged  with  a  series  of  slots,  by  which  the  legs  may  be  se- 
curely fastened  during  the  progress  of  an  operation. 

By  the  use  of  spring  bolts  and  suitable  slots,  the  foot-piece  may  be 
elevated  as  shown  in  figure  183,  in  which  position  the  table  is  adapted  for 
operations  on  the  head  and  neck. 


Figure  184.    Baldwin's  Operating  Table  in  the  Figure  185.    Baldwin's  Operating  Table  in 

Trendelenberg  Position.  Gynecological  Position. 


Two  crutches  are  provided  and  arranged  to  be  attached  to  either  end  of 
the  table.  By  this  means,  what  is  ordinarily  termed  the  head  of  the  table 
may  be  employed  for  perineal  and  similar  operations,  in  which  case  that 
end  of  the  table  may  be  slightly  depressed,  thus  securing  good  drainage. 
Generally  speaking,  this  forms  the  best  end  of  the  table  for  gynecological 
and  rectal  examinations  and  operations,  because  the  table  top  projects 
beyond  the  frame,  thus  allowing  more  space  for  the  knees  of  the  opera- 
tor when  seated.  The  table  is  securely  braced,  strongly  built,  and 
mounted  on  castors  with  rubber  tires.  It  is  finished  in  white  enamel. 
Being  without  complicated  mechanism,  there  is  little  to  get  out  of  order. 
As  it  is  simple  in  construction,  it  may  be  easily  cleaned.  The  joints, 
instead  of  being  painted,  are  either  plated  or  bronzed,  thus  avoiding  the 
danger  to  an  enamel  coat  that  might  be  caused  by  friction  in  moving. 
The  positions  are  simple,  all  being  possible  without  removal  of  the  patient 
from  the  table. 

The  top  is  entirely  of  metal,  with  removable  trough  and  spout.  The 
regular  size  when  the  table  is  horizontal  is  ;  Width  20  inches,  length  72 


OPERATING    TABLES. 


107 


inches,   height  36  inches.     With  foot-piece  depressed  it  is  54  inches  in 
length. 

Baldwin's  Table  May  be  Modified  by  the  construction  of  tops  of  various 
forms  and  material.  Figure  186  exhibits  one  of  these  changes.  As  there 
shown,  it  consists  of  two  heavy  glass  plates  that  form  the  main  body  of  the 
table,  so  arranged  that  they  incline  toward  the  center  of  the  long  diam- 
eter of  the  table  top.  A  longitudinal  trough  placed  beneath  will  conduct 
any  liquids  to  a  receptacle  below.  Instead  of  these  two  plates,  four  may  be 


Figure  186.    Baldwin's  Table  with  Glass  Top. 

provided.  These  may  be  so  placed  that  they  will  drain  toward  the  center 
of  the  table,  both  laterally  and  longitudinally.  Many  operators  prefer  the 
table  with  a  flat  top  either  of  metal  or  of  glass.  It  has  been  suggested 
that  a  warming  chamber  be  placed  underneath  the  table  top,  in  which  hot 
water  may  be  poured  or  conducted,  so  that  the  table  top  may  be  kept  and 
maintained  at  any  desired  temperature. 


Figure  187.     Edebohl-Morris  Operating  Table        Figure  188.    Edebohl- Morris  Operating  Table  with 
with  Extension  Plate.  Stirrups  for  Gynecological  Examinations. 

The  Edebohl-Morris  Operating  Table,  as  portrayed  in  figures  187  to  189,  has 
for  several  years  commanded  a  larger  sale  than  any  previously  designed  hos- 
pital pattern.  It  has  a  heavy  frame,  and  is  solid  and  steady.  Manufact- 
ured with  closely  fitting  joints  and  all  swinging  parts  removable,  it  may  be 
thoroughly  sterilized.  Designed  with  a  metal  trough  underneath  the  main 
table  plate,  an  unlimited  amount  of  water  may  be  utilized  without  danger 
of  wetting  the  surgeon,  assistants,  or  patient's  clothing.  Provided  with  a 
Trendelenberg  attachment,  it  may  be  employed  for  elevating  the  pelvis 
when  required.  Devised  with  a  flat  extension  plate,  it  forms  an  operating 
table  suitable  for  general  surgery.  Constructed  with  a  sliding  shelf  under- 
neath the  table  plate,  it  forms  a  resting-place  for  a  drip  pan,  which  is  not 


108 


OPERATING    APARTMENTS    AND    EQUIPMENT. 


only  out  of  the  way,  but  will  move  with  the  table,  a  great  advantage  in 
clinical  work. 

From  this  statement  it  will  be  seen  that  this  table  will  answer  the 
requirements  of  a  general  operating,  laparotomy  and,  with  the  addition  of 
the  leg  holders  shown  in  figure  194,  a  gynecological  operating  and  examina- 
tion table.  As  pictured  in  figure  187,  it  forms  a  table  20  inches  wide,  70 
inches  long,  and  31  inches  high.  Figure  188  exhibits  the  table  shortened 
to  48  inches  and  with  foot  rests  in  place.  The  change  here  shown  is 
accomplished  by  substituting  the  angular  for  the  straight  extension. 


Figure  189.    Edebohl-Morris  Operating  Table,  showing  Patients  in  Dorsal  and  Trendelenberg 

Positions  for  Operation. 

Figure  189  illustrates  the  patient  in  position  for  gynecological  examina- 
tion or  operation.  The  foot  rests  can  be  turned  outward  or  inward,  as  may 
be  desired.  This  figure  exhibits  the  Trendelenberg  position,  which  may 
be  obtained  after  the  patient  is  on  the  table. 


Figure  190.    Cald well's  Operating  Table. 


Figure  191.    Buchanan's  Operating  Table. 


Caldwell's  Operating  Table,  as  imaged  in  figure  190,  although  simple  in 
construction,  furnishes  either  a  horizontal  top  or  the  Trendelenberg  posi- 
tion. The  latter  may  be  secured  without  unnecessary  labor  or  removing 
the  patient  from  the  table.  While  the  patient  is  lying  upon  the  level  sur- 
face, by  swinging  the  two  supports  shown  in  the  illustration,  the  patient 
and  table  top  will  be  found  so  evenly  balanced  that  the  head  may  be 
depressed  and  the  Trendelenberg  position  secured.  Slots  are  provided  in 
the  foot-piece  by  which  the  lower  limbs  may  be  securely  fastened  with 
bandages,  and  downward  slipping  of  the  patient  prevented.  The  patient 
may  be  as  easily  returned  to  the  horizontal  position.  These  tables  may  be 
constructed  of  any  height  or  length.  As  they  are  manufactured  with  six 


OPERATING    STOOLS. 


109 


legs,  they  rest  firmly  on  the  floor;   and  as  they  are  securely  braced,  the 
table  furnishes  a  solid  support. 

Buchanan's  Operating  Table,  as  displayed  by  figure  191,  consists  of  an 
iron  table  so  arranged  that  it  may  be  folded  flat,  thus  occupying  but  little 
•space  when  required  for  transportation.  The  table  top  is  in  three  sections, 
the  two  outer  of  which  may  be  placed  at  any  angle  or  inclination,  either 
upward  or  downward,  and  as  the  center  may  be  elevated  to  secure  the 
Trendelenberg  position,  any  desired  position  may  be  obtained.  The  table 
may  be  shortened  for  gynecological  use,  and  for  this  purpose  proper  stir- 
rups are  provided.  As  generally  manufactured,  the  table  is  20  inches 
in  width,  31  inches  in  height,  and  when  extended,  72  inches  in  length. 

Operating-  Stools. 

These  are  frequently  required  by  the  surgeon,  particularly  in  case  of 
long  and  tedious  operations.  At  least  one  should  be  included  in  the  arm- 
amentarium of  every  operating-room.  While  an  ordinary  chair  or  stool 
may  answer  every  purpose,  it  is  advisable  to  include  in  an  operating- 
room  no  furniture  excepting  such  as  forms  a  permanent  part  of  the  outfit 
and  that  can  be  readily  cleansed  and  sterilized. 


Figure  192.     Operating  Stool. 


Figure  193.     Andrews'  Operating  Stool. 


The  Operating  Stool  exhibited  in  figure  192  is  of  hollow  wrought  iron 
with  four  legs,  that  it  may  not  be  easily  overturned.  It  is  usually 
manufactured  in  two  sizes,  each  capable  of  varying  height  adjustments. 
The  lower  permits  an  adjustment  of  the  seat  from  19  to  25  inches,  the 
higher  from  25  to  31  inches. 

^Andrews'  Operating  Stool,  as  set  forth  in  figure  193,  has  a  strong  base, 
supported  by  four  legs  of  solid  iron.      The  latter,  by  being  twisted  each 
with  a  brace  rod,  form  a  solid  foundation.     The  seat  is  adjustable,  12  inches 
in  diameter,  and  may  be  varied  to  any  height  from  19  to  26  inches. 
Perineal  Crutches  and  Leg  Holders. 

These  consist  of  supports,  or  braces,  by  which  the  legs  of  a  patient  in 
the  lithotomy  position  may  be  adjusted  and  held  at  any  height  or  angle. 
They  are  employed  principally  in  gynecological,  genito-urinary  and  rectal 
surgery.  One  or  more  forms  are  necessary  in  every  operation-room. 


no 


OPERATING    APARTMENTS    AND    EQUIPMENT. 


The  Plain  Lithotomy  Crutch,  represented  in  figure  195,  is  one  of  the 
most  simple  forms.  In  the  construction  of  the  forked  part,  it  resembles 
the  ordinary  axilla  crutch,  with  which  all  are  familiar.  Each  is  intended 
to  be  placed  beneath  the  knees  in  the  popliteal  space,  and  as  it  can  be 
adjusted  to  any  height,  if  the  forked  part  be  forced  to  the  highest  point, 
that  the  length  of  the  patient's  thigh  will  permit,  the  limbs  will  not  easily 
be  displaced. 


Figure  104.     Edebohl's  Lithotomy  Crutch. 


Figure  195.    Plain  Lithotomy  Crutch. 


Edebohl's  Lithotomy  Crutches,  as  evidenced  in  figure  194,  were  designed 
by  Edebohl  as  an  attachment  to  the  operating  table  described  on  page  107. 
Like  the  pattern  above  described,  they  can  be  adjusted  to  any  height.  Instead 
of  the  forked  part  before  mentioned,  the  ankles  of  the  patient  are  encircled 
by  leather  straps,  ensuring  against  accidental  displacement.  These  supports 
are  curved  near  the  top  to  give  a  greater  or  lesser  amount  of  separation  of 
the  limbs  by  turning  the  bars.  This  principle  is  better  shown  on  the  page 
above  referred  to. 


Figure  I'M.    Clover's  Perineal  Crutch. 


Figure  197.     Kelly's  Leg  Holder. 


Clover's  Perineal  Crutch,  as  shown  by  figure  196,  consists  of  an  adjustable 
steel  bar,  which  can  be  lengthened  or  shortened  at  will.  Each  end  of  the 
bar  is  provided  with  a  steel  leather-covered  band,  of  sufficient  size  to  encir- 
cle the  leg  just  above  the  knee.  When  adjusted  and  secured,  the  knees  of 
the  patient  may  be  spread  to  any  desired  extent.  By  means  of  a  properly 


OPERATING    TABLE    ACCESSORIES.  Ill 

padded  strap  attached  to  the  central  bar,  complete  flexion  of  the  legs  upon 
the  thighs  may  be  made,  the  straps  passed  underneath  the  back  and  prop- 
erly secured,  and  the  surgeon  in  many  cases  enabled  to  operate  with  fewer 
assistants. 

Kelly's  Leg  Holder,  as  traced  in  figure  197,  consists  of  two  canvas  bands 
or  rings  encircling  the  thighs  just  above  the  knees  and  united  by  a  broad 
canvas  strap  that  passes  around  the  neck  of  the  patient.  The  bands  are 
of  heavy  canton  flannel,  double  in  thickness  and  closely  quilted.  These 
bands  are  widest  at  points  of  greatest  pressure,  thus  affording  all  possible 
comfort.  By  means  of  leather  straps  and  metal  rings,  the  whole  is  made 
adjustable  to  any  patient. 

Cover  for  Patient. 

For  better  protection  during  a  laparotomy,  Kelly  suggests  thai  the 
patient  be  covered  with  two  sheets,  one  of  rubber  and  one  of  linen,  the 
centers  of  both  of  which  are  provided  with  an  oblong  opening  of  sufficient 
size  to  furnish  an  unobstructed  view  of  the  field  of  operation,  and  at  the 
same  time  to  provide  the  surrounding  parts  with  a  water-tight  protective. 
The  use  of  this  cover  will  not  only  assist  in  retaining  for  the  patient  a 
larger  percentage  of  body  heat,  but  will  prevent,  in  many  cases,  the  absorp- 
tion that  ensues  when  the  coverings  of  the  patient  come  in  contact  with 
blood,  pus,  fluids  used  for  irrigation,  etc.  It  also  supplies  a  cleanly  cover 
upon  which  to  lay  instruments,  dressings,  etc.,  and  when  properly  steril- 
ized will  lessen  the  danger  of  infection,  as  the  surgeon's  hands  will  not  of 
necessity  come  in  contact  with  the  body  or  clothing  of  the  patient,  or 
the  blankets  or  other  appliances  with  which  the  patient  may  be  sur- 
rounded. 

Covers  for  Operating  Tables. 

Covers  may  be  of  various  substances,  but  those  that  can  be  sterilized 
without  injury  should  be  selected.  They  may  consist  of  folded  blankets,  a 
muslin  sheet,  and  a  layer  of  oil-cloth  or  rubber,  the  latter  being  preferred. 
If  a  table  of  the  pattern  of  figure  181  be  selected,  it  will  be  necessary  to 
have  the  covers  in  duplicate  and  fold  them  in  long  slender  pads  of  the 
same  shape  and  size  as  the  two  table  plates.  Ordinarily,  however,  they 
need  cover  only  the  table  top.  When  desired,  the  rubber  or  oil-cloth  may 
be  somewhat  longer  than  the  table,  so  that  it  may  extend  over  one  end, 
reach  part  way  to  the  floor,  and  there  be  folded  and  fastened  into  a  funnel 
shape,  and  thus  be  utilized  to  conduct  fluids  and  other  discharges  into  a  pail 
or  other  receptacle  and  thus  form  a  substitute  for  a  Kelly  pad. 

N 

Perineal,  General  Surgical  and  Obstetrical  Pads. 

Surgical  pads  are  manufactured  from  soft  rubber  and  consist  of  a  flat 
area  nearly  surrounded  by  a  hollow  inflatable  rim.  One  side  of  the  pad  is 
elongated  into  a  flap  or  apron,  having  a  raised  or  thickened  margin,  the 
construction  being  such  that  fluids  falling  inside  the  limits  of  the  annular 
rim  will  be  conducted  through  its  opening,  by  means  of  the  apron,  into  a 
receptacle  below. 

Kelly's  Circular  Cushion,  as  well  traced  in  figure  198,  is  the  one  in 
general  use.  It  is  manufactured  in  two  sizes,  the  small  one  having  a  pad 
20  inches  in  diameter  with  a  total  length  of  44  inches  while  the  large  pad 
is  24  inches  in  diameter  and  50  inches  in  length. 


112 


OPERATING    APARTMENTS    AND    EQUIPMENT. 


The  Oblong  Perineal  Pad,  displayed  in  figure  199,  is  particularly  adapted 
for  perineal  and  rectal  operations,  and  is  valuable  as  a  part  of  a  traveling 
operating  outfit.  Its  peculiar  shape  enables  the  surgeon  to  fold  it  in  small 
space.  It  is  14  inches  in  width  and  34  inches  in  extreme  length. 

The  Obstetric  Pad,  illustrated  in  figure  200,  is  sometimes  employed  for 
surgical  purposes,  and  consists  of  a  large  pad  similar  to  those  previously 
described,  the  principal  difference  being  in  the  conducting  channel,  which 
is  a  funnel-shaped  pipe,  of  sufficient  diameter  to  admit  of  thorough  disin- 
fection, even  by  scrubbing  with  hot  water  and  antiseptic  solutions.  The 
lower  border  is  formed  over  a  spring,  which  prevents  accidental  closure  of 
the  canal.  A  loop  is  also  provided,  by  means  of  which  the  pad  may  bs 
suspended  for  drainage  or  storage.  All  the  discharges  from  the  mother, 
including  the  child  and  the  placenta,  are  received  in  the  pad,  and  the  bed 
thus  kept  perfectly  clean.  The  pad  will  prove  a  great  boon,  especially  to 
poor  patients. 


Figure  198.    Kelly's  Circular  Surg-    Figure  199.     Kelly's  Oblong 
ical  and  Laparotomy  Pad.  Perineal  Pad. 


Figure  200.     Improved 
Obstetric  Fad. 


Dudley's  Substitute  for  Kelly's  Pad,  as  shown  by  figure  202,  consists  of  a 
piece  of  rubber  sheeting  about  36  by  54  inches.  This  sheet  at  one  end  and  on 
both  sides  is  folded  or  rolled  over  towels,  muslin  or  other  soft  substance,  so 
that,  as  in  the  Kelly  pad,  fluids  may  be  prevented  from  escaping  at  the 
sides,  and  instead  will  be  conducted  into  a  bucket  below.  Almost  any  kind  of 
rubber  sheeting  will  answer  the  purpose,  or  common  oil-cloth  may  be  used. 

Hip  Supports,  Cradles,  Etc. 

These  are  employed  for  raising  any  portion  of  the  body,  either  to  secure 
a  better  position  for  operating,  to  facilitate  drainage,  or  to  assist  in  the 
placing  of  bandages. 

Parkhill's  Cradle,  as  portrayed  in  figure  £03,  consists  of  an  iron  base  to 
which  are  attached  three  arms,  two  upon  one  side,  fixed,  and  one  upon  the 
opposite  side,  movable.  These  arms  are  of  such  size  and  shape  that  they 
may  be  used  to  clasp,  raise  and  fix  any  portion  of  the  trunk  at  the  required 


OPERATING    TABLE    ACCESSORIES. 


113 


height  or  position.  This  pattern  was  designed  especially  for  operations 
upon  the  kidneys,  where  absolute  fixation  is  desirable.  This  is  difficult  to 
secure  with  sand-bags  or  other  devices  placed  under  and  against  the  oppo- 
site loin,  because  of  the  constant  change  of  position,  which  permits  the 
patient  to  turn  or  slip  from  place. 


Figure  201.    Telescoping  Trunk  Support. 

The  apparatus  is  available  in  operations  upon  the  chest,  excision  of 
ribs,  the  thoracoplastic  operation  of  Estlander,  amputations  and  excisions 
at  the  shoulder  joint,  etc.  It  is  also  applicable  in  all  lateral  operations. 


Figure  202.    Dudley's  Substitute  for  Kelly's 
Surgical  Pad. 


Figure  20a     Parkhill's  Cradle. 


The  Telescoping  Trunk  Support,  illustrated  in  figure  201,  consists  of  two 
metallic  plates,  one  flat,  the  other  slightly  concave,  the  two  being  united  by  a 
short,  heavy,  telescoping  tube.  Fixation  of  the  latter  when  extended  is  se- 
cured by  a  bayonet  catch.  The  apparatus  is  employed  for  raising  any  portion 
of  the  trunk,  either  to  better  expose  the  operating  field  or  to  facilitate  the 
application  of  bandages.  It  occupies  but  little  space  and  may  readily  be 
moved  from  place  to  place  as  desired.  The  size  of  the  upper  concave  plate 
is  about  4  by  8  inches,  its  height  is  3  inches,  and  when  extended,  4^  inches. 

Dressing-  Tables. 

Tables  are  required  upon  which  to  place  dressings,  jars,  bottles,  boxes, 
trays,  instruments  in  cases,  splint  material,  and  such  other  apparatus  as  may 
be  necessary  for  use  during  an  operation.  While  they  may  be  constructed 
of  wood  or  iron,  the  latter  is  preferable  for  reasons  before  given. 

The  Plain  Wrought  Iron  Dressing  Table,  sketched  in  figure  204,  has  a  metal 
top  and  frame,  the  whole  sufficiently  well  braced  to  furnish  a  steady  sup- 


114 


OPERATING    APARTMENTS    AND    EQUIPMENT. 


port.  The  legs  are  of  hollow  wrought  iron,  while  the  top  may  be  of  sheet 
iron,  brass  or  copper.  If  of  iron,  it  may  be  either  japanned  or  white  enam- 
eled. If  of  copper,  polished ;  if  of  brass,  nickel-plated.  They  are  usually  of 
two  sizes,  one  24  by  60,  the  other  24  by  36,  with  a  height  of  33  inches. 
When  desired  they  can  be  made  with  a  double  shelf,  thus  greatly  increasing 
the  shelf  space. 

Instrument  Tables. 

At  least  one  instrument  table  is  required  in  every  operating-room. 
They  are  convenient  to  use  for  instruments,  trays,  and  other  appliances 
necessary  in  the  conduct  of  an  operation.  They  should  be  constructed  of 
metal,  with  glass  tops ;  the  shelves,  if  any,  should  be  also  of  glass. 

The  Instrument  Table  displayed  in  figure  205  is  one  of  the  stronger, 
heavier  and  more  durable  patterns.  The  uprights  are  of  tubular  iron,  with 
cross-bars  of  the  same  material,  while  the  supporting  braces  are  of  solid 
iron  carefully  welded  at  points  of  junction.  In  order  that  the  table  may 
remain  firm  and  solid,  it  should  be  provided  with  rubber  crutch  tips,  fitting 


Figure  204.    Plain  Wrought  Iron  Table. 

closely  over  the  bottoms  of  the  legs.     The  glass  top  is  24  inches  in  width, 
36  inches  in  length,  and  the  table  is  31  inches  in  height. 

Suture  Stands  and  Dressing  Cabinets. 

A  separate  stand  or  table  upon  which  to  place  needles,  sutures,  and 
similar  articles  is  not  only  a  great  convenience,  but  almost  a  necessity. 
The  surgeon  should  be  able  to  select  for  himself  from  the  instrument  stand 
such  articles  as  he  desires  to  use  from  time  to  time,  or  he  may  entrust  the 
handling  of  the  instruments  to  a  trained  assistant.  In  the  selection  of 
sutures  and  needles  and  the  threading  of  the  latter,  however,  he  must 
rely  upon  some  one  else,  and  the  attendant  to  whom  the  work  is  entrusted 
should  have  everything  in  readiness  upon  a  separate  stand  devoted  to  this 
purpose.  In  construction  they  should  resemble  instrument  tables,  differ- 
ing only  in  that  they  may  be  smaller. 

The  Suture  Stand  shown  in  figure  207  is  similar  in  construction  to  the 
instrument  table  illustrated  in  figure  205.  As  there  shown,  it  is  strongly 
braced,  and  owing  to  its  peculiar  shape,  occupies  a  small  amount  of  space. 
The  top  is  of  heavy  glass  16  inches  wide  and  21  inches  long,  while  the 
height  is  29  inches.  To  give  the  stand  additional  firmness,  the  leg  bottoms 
are  covered  with  soft  rubber  crutch  tips  of  small  size. 

The  Suture  Stand  exhibited  by  figure  206  has  a  double  shelf.  The  posts 
are  of  angle  iron  strongly  braced,  while  the  stand  is  of  light  and  airy  con- 


INSTRUMENT    STANDS    AND    DRESSING    CABINETS. 


115 


struction,  although  strong  enough  to  meet  all  requirements.  The  addi- 
tional shelf  will  in  many  cases  be  found  convenient  for  storing  packages 
of  sutures,  needles,  etc.  The  usual  size  of  the  top  is  16  by  20  inches,  with  a 
height  of  32  inches. 

The  Instrument  Stand  and  Carriage,  delineated  in  figure  210,  furnishes  a 
carriage  or  stand  that  may  be  utilized  either  in  the  operating-room  or  in 
the  hospital  ward.  Besides  the  stand  top  it  is  arranged  with  two  additional 
shelves,  thus  furnishing  a  large  amount  of  space  for  the  accommodation  of 
appliances.  The  shelves  and  top  are  constructed  with  side  rails  or  guards 
to  prevent  the  displacement  of  articles  arranged  thereon.  Castors  are 
provided  that  the  table  may  be  moved  from  place  to  place.  An  irrigating 
standard  is  placed  at  one  corner,  to  which  a  suitable  reservoir  with  tubing 
and  cut-off  is  attached. 

The  Author's  Dressing  Cabinets  are  displayed  in  figures  208  and  209. 
The  principal  feature  of  these  cabinets  consists  in  a  series  of  quarter- circle 
receptacles,  each  hinged  and  arranged  to  open  independent  of  the  others. 
The  smaller  of  the  two  figures  shows  three  of  these  sections  constructed  in 
a  frame  in  such  a  manner  that  the  cabinet  forms  a  neat  and  attractive 


Figure  205.    Instrument  Table. 


Figure  206.    Suture  Stand. 


stand  that  may  be  utilized  to  good  advantage  in  the  operating-room.  The 
top  is  15  by  24  inches  with  a  height  of  38  inches.  The  larger  pattern  exhibits 
a  utensil  and  irrigating  stand  in  connection  with  the  dressing  cabinet.  On 
the  shelves  of  this  stand,  trays,  dressing  basins,  bowls,  pitchers,  and  other 
articles  may  be  stored.  The  height  is  sufficient  for  the  location  of  irrigat- 
ing bottles.  The  hose  connecting  with  the  latter  may  be  suspended  on  a 
series  of  hooks  attached  to  the  necks  of  the  bottles,  as  shown  in  the  illustra- 
tion. While  these  stands  may  be  made  of  any  size  desired,  the  one  shown 
in  the  illustration  is  15  inches  deep,  50  inches  in  width  and  62  inches  in 
height.  The  compartments  for  dressings  are  16  inches  in  height,  three 
of  them  being  8  inches  and  two  1 2  inches  in  width. 

"Ward  Carriages. 

,  These  are  required  in  hospitals  where  operations  are  occasionally  per- 
formed  in   the  wards  or  apartments  of   the   building.     They   consist  of 


116 


OPERATING    APARTMENTS    AND    EQUIPMENT. 


stands  or  shelves  supported  by  suitable  frames  moimted  on  wheels,  and  so 
adjusted  that  they  may  be  readily  rolled  to  any  portion  of  the  building. 
They  are  intended  to  convey  dressings,  instruments,  and  apparatus  to  the 
place  of  operation. 

The  Berlin  Hospital  Ward  Carriage,  as  displayed  in  figure  211,  consists  of 
a  heavy  wrought  iron  frame  mounted  on  two  24  and  two  1 2-inch  rubber- 
tired,  steel-suspension  wheels,  the  smaller  ones  swiveled  to  admit  of  turning 
the  trucks  in  any  direction.  The  upper  shelf  or  top  consists  of  a  plate  of 
heavy  glass  20  by  50  inches,  surrounded  by  a  suitable  railing  to  prevent 
articles  contained  on  the  shelf  from  falling.  The  lower  shelf  is  1 6  by  36 
inches.  In  the  lower  portion  of  the  carriage  is  a  metal  receptacle  for  dress- 
ing material,  36  inches  long,  16  inches  wide  and  9  inches  deep. 

Instrument  Cabinets. 

A  suitable  place  for  storage  of  surgical  instruments  is  almost  a  necessity. 
Not  only  should  they  be  kept  free  from  contact  with  each  other,  but  they 
should  be  well  protected  from  the  air  and  its  influences.  Instruments  con- 
stantly exposed  not  .only  become  unsightly,  but  rusty,  and  sharp  instru- 


Figure  207.    Suture  Stand. 


Figure  208.    Author's  Small  Dressing  Cabinet. 


ments  soon  lose  their  cutting  edges.  A  desirable  case  in  which  instru- 
ments may  be  neatly  and  tastefully  arranged  should  form  a  part  of  the 
equipment  of  every  hospital.  As  the  cleansing  and  sterilizing  of  the  oper- 
ating-room require  the  constant  use  of  water,  the  instrument  case  and  its 
contents  will  be  the  better  preserved  if  located  in  a  room  adjoining  that 
devoted  to  operations. 

While  instrument  cabinets  may  be  constructed  of  wood,  the  better 
ones  and  those  that  correspond  with  operating-room  furniture,  generally 
are  manufactured  from  steel  or  iron  coated  with  white  enamel.  This  finish 
supplies  a  neat  and  tasteful  exterior,  and  while  not  as  handsome  in  appear- 
ance as  the  nickel-plated  designs,  it  is  as  durable  and  preferable.  In  the 
construction  of  these  cases,  the  utmost  care  should  be  exercised  to  see  that 
all  joints  are  closely  made  and  accurately  fitted.  The  edges  of  the  glass 
shelves  should  be  ground  and  polished,  and  every  precaution  taken  to  ren- 
der the  cases  aseptible. 

In  the  manufacture  of  these  cabinets,  it  will  be  well  if  they  are  supported 
by  suitable  castors  in  order  that  they  may  be  easily  moved  when  the  room 


INSTRUMENT    CABINETS. 


117 


in  which  they  are  contained  is  cleaned  and  sterilized.  That  no  opportu- 
nities be  offered  for  the  permanent  maintenance  of  culture  medium,  they 
should  be  constructed  without  cupboards  underneath  and  without  other 
fixed  base  than  is  necessary  for  the  support  of  the  case. 

The  Double  Instrument  Cabinet,  shown  in  figure  212,  is  one  of  the  better 
patterns  of  this  class  of  cases.  The  sides,  doors  and  shelves  are  all  of  pol- 
ished plate  glass.  Constructed  with  double  doors,  all  parts  of  the  case  are 
easily  accessible.  Mounted  on  heavy  castors,  it  may  be  moved  when 
desired.  The  arrangement  of  the  interior  is  such  that  the  distance  between 
the  shelves  can  be  regulated  at  will.  The  sizes  usually  found  in  the  mar- 
ket vary  from  54  to  72  inches  in  length,  from  30  to  48  inches  in  width,  and 
from  1 6  to  18  inches  in  depth.  Extra  large  cases  with  triple  doors  may 
also  be  obtained.  These  generally  are  72  inches  wide,  72  inches  high  and 
1 8  inches  deep. 


Figure  209.     Author's  Large  Dressing  Cabinet. 


Figure  210.     Instrument  Stand  and  Carriage. 


The  Single  Instrument  Cabinet,  as  shown  by  figure  213,  is  of  the  same  gen- 
eral construction  as  the  pattern  previously  described.  It  differs  only  in 
that  it  is  smaller  and  constructed  with  a  single  door.  Usually  they  are 
made  in  two  sizes,  varying  from  54  to  60  inches  in  height,  from  20  to  30 
inches  in  width,  and  about  16  inches  in  depth. 

Besides  the  cabinets  necessary  for  surgical  instruments,  a  second  case  of 
larger  size  should  be  provided  for  the  storing  of  more  bulky  articles,  par- 
ticularly such  as  can  not  be  sterilized.  In  this  case  should  be  placed  such 
articles  as  the  thermo-cautery,  leg  holders,  perineal  crutches,  perineal  pads, 
splints  and  splint  material,  and  other  appliances  of  similar  character. 


118 


OPERATING    APARTMENTS    AND    EQUIPMENT. 


Wash-Stands  and  Basins. 


In  addition  to  the  ordinary  fixed  sinks  or  common  waslj-stands  with 
which  all  suites  of  operating-rooms  should  be  supplied,  at  least  two  remov- 
able wash-stands  for  the  use  of  the  surgeon  and  his  assistant  at  the  oper- 
ating table  should  be  provided.  This  is  a  necessity,  because  if  the  require  - 


Figure  211.    Berlin  Hospital  Ward  Carriage. 

ments  of  aseptic  surgical  technique  are  to  be  strictly  enforced,  the  surgeon, 
when  making  final  preparation  of  his  hands,  or  washing  during  an  oper- 
ation must  not  use  the  same  bowl,  brush,  soap  or  other  appliances  used 
by  the  assistants. 


Figure  212.    Double  Instrument  Cabinet 


Figure  213.     Single  Instrument  Stand. 


These  basins  should  always  be  within  reach  of  the  surgeon,  so  that,  if 
necessary,  he  may  frequently  cleanse  his  hands  from  blood,  serum  or  other 
extraneous  matter.  Each  basin  or  set  should  rest  upon  a  separate  stand, 


WASH-STANDS. 


119 


which  should  contain  in  addition,  soap  and  brush,  each  in  a  suitable  re- 
ceptacle. 

The  Two  Plain  Wash-Stands,  manifest  in  figures  215  and  216,  are  of  plain 
and  simple  construction.  Manufactured  from  wrought  iron,  they  are  light 
and  easily  sterilized.  Being  provided  with  plain  granite  bowls,  they  can  be 
furnished  at  a  low  price.  The  double  stand  has  commanded  an  extensive 
sale  and  is  a  desirable  pattern. 


Figure  215.     Plain  Single  Wash-Stand. 


Figure  216.    Plain  Double  Wash-Stand. 


The  Revolving  Wash-Stand,  illustrated  in  figure  218,  is  intended  as  an 
accompaniment  to  the  operating  table.  Three  glass  bowls,  each  14  inches  in 
diameter,  are  placed  in  a  frame  which  revolves  around  a  central  shaft. 
That  different  solutions  may  be  employed  and  each  recognized  at  sight,  the 
bowls  are  usually  of  different  colors:  red,  blue  and  crystal  glass.  A  small 
soap-box  rests  upon  the  top  of  the  central  shaft.  The  whole  is  mounted 
upon  a  neat  base  supported  by  castors. 

McBurney's  Wash-Stand,  as  portrayed  in  figure  217,  consists  of  a  bowl 
shaped  like  an  inverted  truncated  cone,  deep  enough  to  permit  the  immer- 
sion of  the  entire  forearm,  and  supported  by  a  strong  stand.  The  bowl  is 
usually  about  9  inches  in  diameter  at  the  top  and  T  5  inches  deep. 


Figure  217.    McBurney's  Wash-Stand.  Figure  218.    Revolving  Wash- Stand. 

The  Arm  Immersion  Bowl,  portrayed  in  figure  219,  is  of  sufficient  size  to 
allow  the  entire  forearm  to  be  submerged.  The  frame  is  of  heavy  construc- 
tion and  mounted  upon  small  light  castors.  The  bowl  is  made  of  heavy 
crystal  glass  and  is  removable  for  emptying. 


120 


OPERATING    APARTMENTS    AND    EQUIPMENT. 


The  Plain  Triple  Wash-Stand,  as  sketched  in  figure  220,  exhibits  a  plain 
stand  with  three  wash-bowls,  each  14  inches  in  diameter.       This  is  a  much 


Figure  219.    Arm  Immersion  Bowl. 


Figure  220.    Plain  Triple  Wash-Stand. 


cheaper  design  than  the  heavier  revolving  pattern  shown  by  figure  218.     As 
shown  in  the  illustration,  it  is  mounted  on  light  castors. 

Floats. 

Floats  are  useful  when  glazed  wash-bowls  are  employed,  so  that  when 
different  solutions  are  exposed  at  the  same  time,  they  may  be  labeled  and 
mistakes  thereby  avoided. 

The  Glass  Float,  depicted  in  figure  221,  represents  a  label  inclosed  in  a 
glass  capsule,  devised  by  Hunter  Robb.  As  the  label  is  alike  upon  both  sides 
and  inclosed  in  a  water-tight  glass  package,  it  will  not  only  float  upon  the 
surface  of  the  liquid,  but  may  be  used  indefinitely.  Their  employment 


Figure  221.    Glass  Float. 

is  recommended  as  a  matter  of  safety,  because  by  their  vise  mistakes  regard- 
ing the  nature  of  a  fluid  exposed  in  a  wash-basin  need  not  occur. 

Bottle  Stands. 

The  Bottle  Stands,  set  forth  in  figures  222  and  223,  each  consist  of  a 
wrought  iron  frame  supported  on  castors  and  containing  two  or  more  glass 
stoppered  bottles,  each  of  which  is  so  pivoted  at  a  point  just  above  its  center 
that  liquids  may  easily  be  poured  from  it  without  danger  either  of  spilling, 
or  of  breaking  the  bottle.  To  insure  safety  from  becoming  overturned,  the 
base  is  made  wide,  giving  a  firm  and  secure  support.  The  bottles  are 
easily  removed.  The  metal  parts  which  come  in  contact  with  the  glass  are 
covered  with  soft  rubber  or  other  suitable  material,  to  prevent  accidental 
breaking  by  jarring.  The  bottles  usually  hold  from  one  to  three  gallons 
each,  and  are  supplied  with  ground  glass  stoppers.  The  stand  may  be 
procured  with  2,  4,  6  or  8  bottles. 


BOTTLE    STANDS    AND    IRRIGATORS. 


121 


Irrigators. 

These  consist  of  some  form  of  reservoir  for  liquids,  provided  with 
suitable  rubber  hose  by  which  a  stream  of  the  contained  solution  may  be 
conducted  to  the  operating  field.  When  in  use,  great  care  should  be  exer- 
cised to  see  that  they  are  kept  free  from  infection.  Much  attention  should 
be  given  to  the  rubber  hose,  which  should  be  frequently  and  thoroughly 
cleansed  and  sterilized.  The  points  should  be  removed  after  every  oper- 
ation, that  they  may  be  systematically  disinfected  with  the  balance  of  the 
appliances  in  use. 

Irrigators  may  be  manufactured  from  various  materials,  such  as  glass, 
porcelain,  soft  rubber,  metal,  etc. 

The  Glass  Irrigator  with  Handle,  as  set  forth  in  figure  224,  consists  of  a 
cylindrical  vessel  with  flat  bottom,  a  flat  back,  pitcher-shaped  handle,  and 
a  side  opening  at  the  bottom.  A  hole  in  the  back  near  the  top  permits  of 


Figure  232.     Bottle  Stand  with  4  Bottles. 


Figure  223.     Bottle  Stand  with  8  Bottles. 


suspension  against  the  wall,  while  its  general  shape  admits  of  its  being 
placed  on  a  shelf  or  stand.  They  may  be  purchased  either  plain  or  grad- 
uated and  of  i,  2,  3  or  4  quart  capacity. 

The  Barrel  Form  Irrigating  Jar,  as  depicted  in  figure  227,  is  an  apparatus 
that  has  long  been  popular  in  European  hospitals.  It  consists  of  a  barrel- 
shaped  reservoir,  manufactured  from  porcelain,  provided  with  a  suitable 
cover,  and  with  an  opening  at  the  bottom  into  which  is  inserted  a  tube  and 
stopper,  by  which  connection  is  made  with  a  soft  rubber  hose  and  ter- 
minal pipes.  Their  solidity,  the  fact  that  they  will  withstand  the  action 
of  acids,  and  that  they  may  be  obtained  in  large  sizes,  render  them  suitable 
to  the  requirements  of  hospitals.  They  are  particularlj7'  adapted  as  con- 
tainers for  such  liquids  as  are  damaged  by  the  action  of  light.  The  usual 
sizes  are  i,  2  and  4  gallons. 

The  Hospital  Irrigating  Jar,  represented  in  figure  225,  consists  of  a  glass 
reservoir,  semi-circular  in  form,  flat  upon  one  side,  and  the  under  part 


122 


OPERATING    APARTMENTS    AND    EQUIPMENT. 


funnel-shaped.  The  flattened  side  is  constructed  with  an  upward  extension 
or  flange  containing  a  small  hole  or  opening,  thus  enabling  the  operator  to 
hang  the  apparatus  upon  a  nail  or  hook  in  the  wall.  The  front  may  be 
plain  or  graduated,  as  shown  in  the  illustration.  They  may  be  obtained  in 
i,  2,  3  or  4  quart  size.  Irrigating  points  maybe  attached  by  a  rubber  hose. 
The  Irrigating  Bottle,  depicted  in  figure  226,  consists  of  a  glass  stoppered 
bottle  of  extra  thickness,  provided  near  its  bottom  with  a  second  opening  to 
which  a  soft  rubber  hose  of  such  length  as  may  be  desired,  is  attached  'by 
means  of  a  tube  and  stopper.  This  pattern  is  preferred  for  such  solutions 
as  are  not  damaged  by  the  action  of  light.  They  may  be  of  i,  2,  3  or  5 
gallon  capacity. 

Irrigating  Pipes. 

These  may  be  manufactured  of  glass,  hard  rubber  or  metal,  the  first 
mentioned  being  usually  preferred,  and  of  any  desired  form. 


Figure  224.    Glass  Irrigator    Figure  235.  Hospital    Figure  226.  Irrigat-      Figure  227.  Porcelain  Irrigat- 
with  Handle.  Irrigating  Jar.  ing  Bottle.  ing  Jar. 

The  Plain  Irrigating  Pipes,  portrayed  in  figure  228,  are  of  glass  and  may  be 
of  any  desired  size.  "A"  illustrates  a  pipe,  the  internal  diameter  of  which 
at  the  point  should  be  but  little  less  than  that  of  the  rubber  hose  to  which 
it  is  attached.  This  is  intended  to  supply  a  current  of  little  force,  where 
flushing  by  filling  or  saturation  is  desired. 

"B"  illustrates  a  second  pattern  contracted  at  its  outer  opening.  Such 
a  pipe  will  discharge  a  stream  with  more  or  less  force,  the  extent  of  which 
is  regulated  by  the  amount  of  constriction  at  the  distal  end  of  the  tube.  It 
is  applicable  in  cases  where  force  is  desired,  and  may  be  utilized  to  dissolve 
and  wash  away  purulent  discharges,  adherent  dressings,  scrapings  of  bone 
or  tissue,  clotted  blood,  etc. 

Cut-Offs. 

These  may  be  procured  in  several  forms  and  patterns,  varying  from  the 
ordinary  metal  clamp  in  common  use  with  fountain  syringes,  to  the  more 
elaborate  clamps  shown  by  the  following  figures. 

The  Esmarch  Cut-Off,  as  displayed  in  figure  229,  combines  the  popular  form 
of  cut-off  and  nozzle  in  one  appliance,  and  forms  a  convenient  and  desirable 


IRRIGATING    EQUIPMENT. 


123 


instrument.  A  lever  in  the  center,  placed  where  it  may  be  controlled  by 
thumb  movement,  stops  or  regulates  the  flow  at  the  will  of  the  operator. 
This  design  is  usually  preferred  to  those  patterns  requiring  separate  cut- 
offs and  pipes.  It  possesses  another  advantage  in  that  it  does  not  compress 
the  tube  in  shutting  off  the  flow  of  liquid.  It  is  well  known  that  the  clos- 
ing of  a  rubber  tube  for  any  considerable  length  of  time  flattens  the  lumen, 
frequently  to  such  an  extent  that  it  will  not  re-open  when  the  pressure  is 
removed. 

The  Ordinary  Metal  Cut-Off,  as  illustrated  in  figure  230,  is  one  of  the  most 
common  forms  in  use.  It  is  this  pattern  that  is  usually  employed  in  the 
management  of  fountain  syringes.  Its  use  is  generally  restricted  to  tubing 
of  small  caliber  with  thin  or  medium  walls. 

B 


Figure  238.    Plain  Glass  Irrigating  Pipes. 

Pratt's  Tube  Compressor,  as  pictured  in  figure  231,  is  of  sufficient  size  to 
furnish  a  full-handed  grip.  The  tube  is  compressed  by  means  of  a  strong 
self-acting  spring  that  permits  a  flow  only  when  depressed.  A  sliding 
barrel  is  arranged  to  pass  under  the  lever,  so  that  when  flow  is  required 
for  a  considerable  length  of  time,  the  pressure  on  the  tube  is  relieved  and  a 
continued  hand  force  is  not  necessary.  This  may  also  be  used  to  release 
pressure  from  the  tube  when  the  cut-off  is  not  in  service.  It  may  be  used 
in  connection  with  tubing  having  an  internal  diameter  of  %  inch. 

Irrigating-  Stands. 

The  Oblong  Irrigating  Stand,  explained  by  figure  232,  is  intended  for  use 
with  ordinary  irrigating  bottles.  It  consists  of  an  iron  truncated,  pyramidal 
frame,  supplied  with  a  metal  top  and  having  near  its  bottom  a  metal  shelf. 


Figure  229.    Esmarch's  Cut-off. 

Usually  they  are  about  75  inches  in  height,  12%  inches  square  on  the 
top,  with  a  shelf  18  by  22  inches.  The  stand  may  be  mounted  on  rubber 
castors,  so  that  it  can  be  moved  at  will.  This  enables  the  operator  to  bring 
it  in  close  proximity  to  the  operating  table  when  the  use  of  a  douche  is 
required,  after  which  it  may  be  moved  out  of"  the  way  of  the  surgeon  and 
attendants. 

The  Irrigating  Stands,  pictured  in  figures  234  and  235,  show  two  forms, 
one  fixed,  the  other  adjustable  to  any  desired  height.  They  each  have  a 
wrought  iron  standard  and  cast  iron  base.  The  latter  should  always  be  of 
good  breadth  and  weight  so  as  to  give  stability  to  the  apparatus. 

The  Author's  Double  Irrigating  Stand  is  sketched  in  figure  233.  The 
various  patterns  of  irrigating  stands  heretofore  in  use  were  deemed  in- 


124 


OPERATING    APARTMENTS    AND    EQUIPMENT. 


adequate  to  the  necessary  requirements  of  such  an  appliance,  and  to  meet 
what  appeared  to  be  an  urgent  demand,  the  design  here  shown  was  per- 
fected after  some  experiments.  It  consists  of  a  strong  cast  iron  base  in 
the  form  of  double  cross-pieces,  to  the  center  of  which  is  attached  a  perpen- 
dicular telescoping  shaft  so  arranged  that  it  may  be  adjusted  to  any 
height.  At  its  upper  extremity  two  arms  of  goose-neck  shape  extend  in 


Figure  230.     Ordinary  Metal  Cut-Off. 


Figure  231.    Pratt's  Tube  Compressor. 


opposite  directions.  From  these  arms  two  conical  percolators  are  sus- 
pended, by  means  of  metal  handles  and  bales.  By  the  aid  of  a  suitable  con- 
nector, a  piece  of  rubber  hose  is  attached  to  each  of  the  percolators,  each 
terminating  in  an  Esmarch  cut-off,  as  illustrated  by  figure  229. 

The  percolators  may  be  of  either  glass  or  glazed  iron,  the  former  en- 
abling the  attendants  to  note  the  quantity  of  fluid  in  the  jar.     The  glazed 


v£ 


v® 


s» 


Figure  232.    Oblong    Figure  233.     Author's 
Irrigating  Stand.  Irrigating  Stand. 


Figure  234.  Figure  235.     Figure  236.     Bard's  Irrigat 

Adjustable  Plain  Irrigat-                  ing  Stand. 

Irrigating  ing  Stand. 
Stand. 


iron  percolators  may  be  of  granite  or  similar  ware  which  is  practically 
indestructible.     All  should  be  provided  with  closely  fitting  metal  covers. 

Bard's  Folding  Irrigating  Stand,  as  displayed  in  figure  236,  exhibits  an 
irrigating  apparatus,  the  flow  of  which  can  be  regulated  by  foot  pressure. 
This  is  of  great  utility  where  the  number  of  assistants  are  limited.  This 
advantage  is  secured  by  means  of  a  spring  cut-off,  arranged  in  connection 
with  the  upright  shaft  and  operated  by  a  lever  in  the  base  of  the  instru- 


IRRIGATING     EQUIPMENT. 


125 


ment.  A  lateral  opening  through  the  stand  is  provided,  through  which  the 
rubber  hose  passes.  A  central  rod  forced  upward  by  a  spiral  spring  opens 
or  closes  the  hose  by  compression.  This  rod  is  controlled  by  a  pedal  in  such 
manner  that  the  operator  is  enabled  to  instantly  start  or  arrest  the  flow  of 
liquid  from  the  reservoir. 

The  apparatus  is  so  arranged  that  in  cases  where  a  continuous  flow  for 
some  time  is  necessary,  the  pedal  and  spring  may  be  controlled  by  a  bay- 
onet catch,  thus  relieving  the  foot  of  the  operator  from  service.  Ordinarily 
they  are  constructed  in  two  patterns,  one  with  a  fixed,  the  other  with  a 
detachable  base,  the  latter  unjointing  for  transportation.  The  shaft  is  of  a 


Figure  237. 


Bottle,  Irrigating  and  Tray 
Stand. 


Figure  238.    Irrigating  Stand  with  Heater. 


telescoping  pattern  so  that  the  entire  apparatus  may  be  compactly  folded. 
While  the  reservoir  may  be  of  any  desirable  material,  soft  rubber  will  be 
found  preferable,  and  the  four-quart  size  is  usually  employed.  This  form 
of  pedal  cut-off  may  be  attached  to  hospital  irrigating  stands. 

The  Bottle,  Irrigating  and  Tray  Stand,  defined  by  figure  237,  consists  of 
t\vo  conical  irrigators  and  four  solution  bottles,  together  with  two  glass 
trays,  the  latter  mounted  on  jointed  arm  brackets.  The  irrigators,  each 
complete  with  discharge  pipe  and  cut-off,  are  suspended  from  bayonet- 
shaped  shafts  that  may  be  adjusted  to  any  desired  height.  The  four  solu- 
tion bottles  are  contained  in  hinged  frames  in  such  a  manner  that  the  con- 


126 


OPERATING    APARTMENTS    AND    EQUIPMENT. 


tents  may  be  easily  withdrawn.  The  glass  trays  are  hela  in  place  by 
brackets  that  may  be  regulated  to  various  sizes.  The  stand  is  strongly 
built  and  mounted  on  a  frame  with  heavy  castors. 

The  Irrigating  Stand  with  heater,  shown  in  figure  238,  furnishes  means 
for  irrigating  with  warm  solutions  without  the  necessity  of  filling  the  bot- 
tles with  hot  fluids  during  an  operation.  The  apparatus  consists  of  two 
irrigating  bottles  mounted  on  a  strong,  upright  frame  supplied  with  heavy 
rubber-covered  castors.  The  bottles  may  be  adjusted  to  various  heights  as 
required.  A  tank  with  lamp  is  provided,  the  former  containing  a  coil  of 


Figure  239.     Metal  Trough  for 
Soiled  Dressings,  etc. 


Figure  340.     Plain  Slop  Bucket. 


Figure  241.     Improved  Slop 
Bucket. 


sufficient  length  to  allow  fluid  passing  through  it  to  become  heated  to  the 
desired  temperature. 

Refuse  Boxes  and  Jars. 

Receptacles  in  which  to  place  all  forms  of  septic  material  are  a  necessity 
in  the  operating-room.  It  is  essential  that  all  refuse  containing  infective 
germs  be  safely  stored  where  it  will  not  be  brought  in  contact  either  with 
the  air,  clothing,  dressings  or  aseptic  substances  until  it  can  be  safely  taken 
from  the  room  and  disposed  of. 


Figure  242.     Glass  Surgical  Tray. 


Figure  243.    Porcelain  Surgical  Tray. 


Infected  dressings,  sponges  and  masses  of  tissue  should  not  be  thrown 
upon  the  floor,  because  such  action  may  result  in  contaminating  the  shoes 
and  slippers  of  the  attendants,  thus  enabling  them  to  convey  septic  organ- 
isms to  various  parts  of  the  operating  and  adjoining  rooms.  Refuse  recep- 
tacles may  consist  of  troughs,  boxes,  buckets,  etc. 

The  Metal  Trough  for  soiled  dressings,  etc.,  shown  in  figure  239,  is  pro- 
vided with  suitable  covers,  that  it  may  be  readily  opened  and  its  contents 
easily  removed.  The  corners  are  well  rounded,  so  that  it  presents  no  sharp 
angles  for  the  accumulation  of  filth  and  septic  matter.  Castors  and  han- 
dles are  provided,  by  means  of  which  it  may  be  easily  moved  from  place 
to  place.  Generally  they  are  18  by  18  by  20  inches. 


SURGICAL     TRAYS.  127 

The  Plain  Slop  Bucket,  depicted  in  figure  240,  is  the  form  in  common 
use.  It  consists  of  a  pail  with  suitable  cover,  made  of  enamel  ware. 
Usually  they  are  of  3-gallon  capacity. 

The  Improved  Slop  Bucket,  exhibited  in  figure  241,  is  of  an  improved 
design,  one  that  serves  to  prevent  the  escape  of  any  odor.  Fluids  are  ad- 
mitted to  the  pail  through  a  valve  fitting  closely  in  the  cone-shaped  cover. 
This  cover  may  be  removed  when  dressings  or  other  similar  articles  are  to 
be  thrown  in. 

Surgical  Trays. 

Several  trays  are  necessary  for  a  proper  division  of  the  appliances  nec- 
essary in  an  operation.  One  should  contain  the  cutting  instruments,  tissue 
forceps,  directors,  etc. ;  a  second,  artery  forceps  and  other  hemostatic 
instruments ;  a  third  should  be  of  larger  size,  in  which  may  be  placed  the 
heavier  instruments,  such  as  retractors,  bone  instruments,  and  other 
appliances  of  like  character;  a  fourth,  the  needles  and  ligatures,  while  a 
fifth  should  contain  the  sponges  or  their  substitutes.  They  usually  consist 
of  shallow  flat  basins  of  some  material  that  may  be  easily  cleansed  and 
sterilized.  They  may  be  constructed  of  glass,  granite  iron  or  similar  glazed 
material,  hard  rubber,  soft  rubber  and  porcelain. 

The  most  satisfactory  trays  for  this  purpose  are  of  heavy  glass,  for  they 
not  only  possess  the  advantage  of  being  easily  sterilized  by  mechanical  and 
chemical  measures,  but  they  present  an  air  of  cleanliness  not  common  to 


TRUWX-GHEENEaCO.. 

Figure  244.    Author's  Surgical  Tray.  Figure  245.    Plain  Enamel  Ware  Surgical  Tray. 

utensils  manufactured  from  any  other  material.  Their  smooth  surfaces 
may  easily  be  cleansed  with  soap,  water  and  brush,  supplemented  by 
germicidal  solutions  of  extra  strength. 

The  Glass  Surgical  Tray,  disclosed  in  figure  242,  is  preferred  by  many 
operators  for  the  reasons  given  above.  To  be  serviceable,  trays  should  be 
manufactured  of  the  best  quality  of  heavy  flint  glass.  They  may  be  pro- 
cured in  sizes  ranging  from  7  to  18  inches  in  length. 

The  Porcelain  Surgical  Tray,  exhibited  in  figure  243,  is  similar  to  those  in 
use  by  photographers.  They  are  preferred  by  many  surgeons  because  of  the 
extreme  ease  with  which  they  may  be  cleansed  and  sterilized,  mechanically, 
chemically  or  thermally,  and  because  the  character  of  any  solution  contained 
in  them  may  usually  be  determined  by  its  color.  Small  appliances,  such  as 
needles,  ligatures,  etc.,  may  easily  be  recognized  because  of  the  white  back- 
ground. They  are  provided  with  a  lip  by  which  the  fluid  contents  may  be 
poured  off.  They  may  usually  be  obtained  in  sizes  varying  from  8  to  15 
inches  in  length. 

The  Surgical  Tray,  exhibited  in  figure  244,  illustrates  a  pattern  first 
suggested  by  the  author.  Its  principal  features  of  advantage  consist  in  a 
series  of  ridges  extending  transversely  across  the  bottom  of  the  tray,  and 
the  elongation  of  one  corner  into  a  suitable  lip  by  which  the  contents  of  the 
tray  may  be  easily  poured  off.  The  ridges  above  referred  to  possess  the 


128 


OPERATING    APARTMENTS    AND    EQUIPMENT. 


advantage  of  serving  to  prevent  small  and  straight  instruments  from  resting 
on  the  bottom  of  the  tray. 

This  is  a  convenience  to  the  surgeon,  particularly  when  he  wishes  to 
pick  up  an  instrument  in  haste.  They  are  made  in  but  one  size,  9  by  15 
inches. 

The  Plain  Enamel  Surgical  Tray,  shown  in  figure  245,  is  the  ordinary 
form  of  baking  pan  largely  used  for  surgical  trays,  particularly  when 
funds  are  limited  and  economy  necessary.  They  are  usually  of  granite  or 
agate  ware,  and  of  sizes  varying  from  12  to  20  inches  in  length. 

Jars  for  Dressings,  Ligatures,  Etc. 

These  are  intended  for  the  storage  of  sterilized  dressings,  such  as  gauze, 
bandages,  cotton,  towels,  etc.  Various  forms  of  boxes,  bottles,  jars,  etc., 
have  been  devised  and  are  in  use  for  this  purpose.  The  objection  to  wooden 
and  metal  receptacles  has  been  because  of  the  difficulty  of  sterilization. 
Ordinary  glass  bottles  are  unhandy  because  of  the  smallness  of  their  mouths 
or  openings.  Ordinary  jars  with  glass  covers  are  easily  broken,  and  unless 
firmly  pressed  down,  the  cover  does  not  form  a  tight  joint. 

O'Neil's  Dressing  Jar,  as  portrayed  in  figure  246,  forms  the  most  conven- 
ient and  desirable  pattern  of  dressing  jar  of  which  we  have  any  knowledge. 


Figure  246.     O'Neil's 
Dressing  Jar. 


Figure  247.     Glass  Box  for  Pins, 
Needles,  etc. 


Figure  248. 


Ligature  and  Dress- 
ing Jar. 


It  is  composed  of  heavy  crystal  glass  blown  with  a  projecting  rim,  and 
forms  a  solid  receptacle  not  easily  broken.  The  cover  is  of  metal,  polished 
and  nickel  plated,  a  portion  of  it  fixed  to  the  jar,  the  balance  hinged  that  it 
may  be  easily  lifted.  It  is  attached  to  the  jar  by  a  metal  band  that  sur- 
rounds and  incloses  the  glass  rim  previously  referred  to.  A  staple  and 
padlock  are  provided,  that  the  contents  may  not  be  disturbed  by  septic 
hands.  As  light  is  freely  admitted  to  the  interior,  the  attendants  may  at 
all  times  note  the  quantity  and  character  of  contents.  They  may  be  pro- 
cured in  diameters  varying  from  9  to  15  inches. 

The  Shallow  Glass  Box,  portrayed  in  figure  247,  illustrates  a  more  simple 
form  of  box  with  close  fitting  covers,  intended  for  needles,  pins,  silver 
wire,  etc.  They  may  be  obtained  in  sizes  varying  from  2  to  4  inches  in 
diameter. 

The  Ligature  and  Dressing  Jar,  outlined  in  figure  248,  for  the  preserva- 
tion of  ligatures  is  one  of  the  most  useful  designs  in  the  market.  In  jars 
of  this  pattern,  ligatures,  dressings,  bandages,  drainage  tubes  and  small 
appliances  generally  may  be  stored  and  maintained  comparatively  free  from 
air  infection.  They  are  of  heavy  flint  glass,  and  may  be  obtained  in  sizes 


JARS,    BOTTLES    AND    FLASKS. 


129 


varying  from  3  to  8  inches  in  diameter.      The  covers  are  of  glass  sup- 
plied with  knobs,  by  which  they  may  be  easily  removed  and  handled. 

Bottles  and  Flasks. 

These  are  required  for  the  storage  of  various  forms  of  liquids,  etc.  They 
should  be  of  heavy  glass,  and  when  used  for  acids,  corrosive  sublimate  and 
strong  antiseptics,  should  be  provided  with  glass  stoppers.  When  em- 
ployed for  sterilized  water,  the  stopper  should  consist  of  a  ball  of  closely 
compressed  non-absorbent  cotton.  These  bottles  may  be  obtained  in 
various  forms^  the  ordinary  druggist's  shelf  bottle  being  largely  employed. 

The  Druggist's  Shelf  Bottles,  displayed  in  figures  249  and  250,  may  be 
used  to  advantage  on  account  of  their  low  price.  They  are  too  familiar  to 
all  to  require  description.  They  may  be  obtained  in  sizes  varying  from 
i  ounce  to  i  gallon. 

The  Anatomical  Jar,  set  forth  in  figure  251,  is  well  adapted  not  only  for 
the  exhibition  of  anatomical  specimens,  but  for  the  storage  of  rubber  liga- 
tures, drainage  tubes,  and  some  forms  of  sutures.  They  are  made  of  heavy 
glass  with  flat  glass  covers,  the  space  between  the  cover  and  the  jar  being 
filled  with  a  rubber  band,  and  the  two  parts  held  together  by  a  strong 


Figure  249.     Druggist's 
Shelf  Tincture  Bottle. 


Figure  250.    Druggist's 

Shelf  Salt  Mouth 

Bottle. 


Figure  251.  Anatom- 
ical Jar. 


Figure  252.    Chemical 
Flask. 


metal  clamp  supplied  with  a  pressure  screw.  They  will  be  found  useful  in 
every  hospital  and  may  be  obtained  tall  or  flat,  in  sizes  ranging  from  3  to 
9  inches  in  diameter  and  from  5  to  36  inches  in  height. 

The  Chemical  Flask,  depicted  in  figure  252,  illustrates  the  ordinary  pat- 
tern which  is  largely  used  for  storing  sterilized  water  and  solutions  in  the 
laboratory  and  operating-room.  They  are  preferred  by  many  because  they 
are  not  easily  overturned,  and  the  long  neck  affords  a  good  grip.  The  fact 
that  they  are  not  constructed  with  glass  stoppers  is  an  advantage,  as  an  un- 
ground  surface  is  more  easily  sterilized. 

Objections  have  long  been  made  to  the  use  of  these  flasks  for  the  pur- 
pose of  storing  sterilized  water,  as  it  is  claimed  that  if  sterile  water  be 
placed  in  a  sterilized  bottle  of  this  character,  it  cannot  be  poured  from  the 
bottle  without  contamination,  because  of  the  air  infection  that  must  result 
after  exposure  of  the  lip  or  mouth  of  the  bottle. 


130 


OPERATING    APARTMENTS    AND    EQUIPMENT. 


Parkhill's  Bottle  Mouth  Sterilizer,  as  set  forth  in  figure  253,  is  an  alcohol 
lamp  so  arranged  as  to  furnish  a  circular  flame  that  will  completely  en- 
velop the  lip  and  mouth  of  an  inclosed  bottle  and  by  flame  contact  secure 
surgical  sterilization.  Laboratory  experiments  have  demonstrated  the 
success  of  this  appliance,  and  as  many  surgeons  keep  a  supply  of  sterile 
water  in  jars  of  this  character,  we  believe  the  apparatus  will  prove  of  great 
advantage.  It  is  constructed  of  copper  and  is  mounted  upon  three  hollow 
copper  legs,  so  adjusted  that  the  lamp  will  rest  upon  the  bottle  as  shown  in 


Figure  253.     Parkhill's  Bottle  Mouth  Sterilizer. 


the  illustration.  A  small  tube  covered  by  a  cap  admits  of  the  filling  of  the 
reservoir  with  alcohol.  This  chamber  is  tightly  packed  with  asbestos,  so 
that  a  flame  may  be  maintained  for  a  considerable  length  of  time.  A  small 
non-conducting  handle  of  wood  enables  the  operator  to  manipulate  the 
sterilizer  at  will.  The  partially  burned  and  charred  cotton  plug  used  as  a 


Figure  254.     Oblong  Glass  Box  for  Dressings,  etc. 


Figure  255.     lodoform  Gauze  Box. 


stopper  for  the  bottle  should  not  be  removed  until  after  the  sterilization  is 
complete,  and  then  only  with  sterile  forceps. 

Dressing  Boxes. 

These  will  be  found  useful  for  storing  gauze,  towels,  bandages,  some 
forms  of  instruments  and  appliances,  etc. 

The  Oblong  Glass  Box,  pictured  in  figure  254,  is  well  adapted  for  the 
purpose  above  set  forth.  They  may  usually  be  obtained  in  sizes  varying 
from  6  to  12  inches  in  length. 

The  lodoform  Gauze  Box,  illustrated  by  figure  255,  is  a  pattern  designed 
for  storing  iodoform  gauze.  It  consists  of  an  oblong  glass  box,  in  the  center 
of  which  a  roll  of  the  gauze  is  supported  by  a  wire  axle,  one  end  of  which  is 


LIGATURE    BOXES. 


131 


formed  in  the  shape  of  a  crank.  The  gauze  is  prepared,  rolled  tightly  like 
an  ordinary  bandage,  and  held  in  place  in  the  glass  box,  while  the  wire 
axle  is  passed  through  it,  after  which  it  may  be  unrolled  and  pieces  of 
proper  length  cut  from  it  as  desired. 

Ligature  Boxes. 

In  order  that  ligatures  ready  for  use  may  be  stored  in  antiseptic  solu- 
tions without  danger  of  becoming  entangled  or  knotted,  ligature  boxes 


Figure  256.    Glass  Ligature  Boi 


Figure  257.    Glass  Ligature  Box. 


These  are  usually  made  of 
The  glass  should  be  carefully 


provided  with  suitable  reels  are  necessary, 
glass,  and  may  be  obtained  in  various  sizes, 
annealed,  in  order  to  avoid  risk  of  breakage. 

The  Glass  Ligature  Box  shown  in  figure  256  illustrates  one  of  the  smaller 
patterns  of  this  class  of  boxes.  It  consists  of  three  small  glass  reels  mounted 
on  a  suitable  shaft,  the  latter  supported  by  an  arch  composed  of  a  single 
piece  of  flint  glass.  In  the  upper  portion  of  the  arch  at  points  directly  over 


Figure  258.    All  Glass  Ligature  Box,  4  Large  Spools,  Hagedorn's  Model. 

the  center  of  each  reel,  three  openings  are  provided,  through  which  the  ends 
of  the  ligatures  may  be  passed.  That  they  may  not  slip  back  underneath 
the  arch,  suitable  glass  plugs  or  wedges  are  provided  for  holding  in  place 
the  ligature  ends.  As  the  point  of  exit  is  below  the  water  line,  there  is 
no  danger  of  the  ends  of  the  ligatures  becoming  contaminated. 

The  Ligature  Box  set  forth  in  figure  257  illustrates  one  containing  two 
spools  of  extra  size,  mounted  on  a  heavy  glass  shaft,  the  whole  supported 
by  a  well-constructed  glass  frame.  This  apparatus  is  provided  with  an 


132 


OPERATING    APARTMENTS    AND    EQUIPMENT. 


inner  cover  having  two  openings,  through  which  the  ligatures  are  drawn. 
Two  suitable  glass  plugs  prevent  the  ligatures  from  slipping  backward, 
but  permit  them  to  be  easily  drawn  from  the  reel.  The  cover  is  of  heavy 
glass  surmounted  by  a  knob. 

Hagedorn's  Glass  Ligature  Box,  as  illustrated  in  figure  258,  resembles  the 
one  last  described,  differing  only  in  size ;  it  is  provided  with  four  reels 
instead  of  two. 

Dressing  Basins. 

These  may  be  obtained  of  various  materials,  such  as  flint  glass,  granite 
or  enamel  ware,  hard  rubber,  papier  mache,  and  metal.  The  use  of  flint 
glass  is  confined  to  hospitals  where  an  exhibit  of  immaculate  cleanliness  is 


Figure  260.    Plain  Dressing  Basin. 


Figure  261.    Smith's  Dressing  Basin. 


made  an  important  feature,  and  where  flint  glass  utensils  are  used  wher- 
ever it  is  possible  to  employ  them. 

Granite  or  enamel  ware  forms  the  next  best  material  to  glass  in  point 
of  cleanliness,  and  on  account  of  its  much  lower  price  and  greater  dura- 
bility is  usually  preferred.  Such  basins  are  easily  sterilized  by  boiling,  and 
for  this  reason  are  preferred  by  many  surgeons. 

The  Plain  Dressing  Basin,  set  forth  in  figure  260,  may  be  obtained  of 
various  materials  and  sizes.  Glass  basins  are  made  in  sizes  that  vary 
from  6  to  13  inches  in  length.  Enamel  ware  is  now  largely  used,  and 
sizes  that  vary  from  6  to  12  inches  in  length  may  be  procured.  Hard 
rubber,  papier  mache  and  metal  are  now  little  used  for  this  purpose,  but  may 
be  obtained  in  similar  sizes. 

Smith's  Dressing  Basin,  as  disclosed  in  figure  261,  possesses  some  advan- 
tages not  found  in  the  ordinary  patterns.  It  is  constructed  with  an  outline 
composed  of  curves  of  various  sizes  and  shapes,  so  adjusted  that  it  may  be 
made  to  fit  the  contour  of  almost  any  portion  of  the  body.  It  can  thus  be 
made  useful  in  receiving  the  contents  of  abscesses,  in  collecting  blood  dur- 
ing profuse  hemorrhage,  and  in  catching  the  fluids  incident  to  irrigation. 
The  length  of  this  pattern  is  12  inches.  It  is  usually  constructed  of  granite 
or  agate  ware. 


CHAPTER  VI. 


APPAREL  EQUIPMENT  OF  SURGEONS, 
NURSES,   ETC. 

The  clothing  and  other  outward  apparel  worn  by  the  surgeon,  assistants, 
and  patient  during  operations  should  be  aseptic.  This  condition  requires 
special  garments,  robes,  aprons,  coats,  etc.  While  many  surgeons  insist 
that  this  rule  should  apply  to  all  persons  admitted  to  the  operating-room,  it 
relates  with  greater  force  to  those  who  come  in  actual  contact  with  the 
patient.  The  appliances  in  use  for  protecting  the  patient  from  the  oper- 
ator and  assistants,  and  for  protecting  the  surgeon  from  blood  and  other 
fluids,  consist  principally  of  surgeons'  and  assistants'  operating  suits  and 
aprons,  male  nurses'  operating  suits,  female  nurses'  gowns,  patients'  suits, 
and  coats  for  spectators. 

If  those  in  charge  of  operating-rooms  insist  that  all  persons  admitted  to 
the  arena  be  clothed  in  sterile  apparel,  one  source  of  infection  would  be 
excluded.  Contamination  may  easily  occur  by  contact  of  a  sleeve  or  other 
portion  of  a  sterile  garment  with  the  non-sterile  coat  or  person  of  an  assist- 
ant or  spectator.  Safety  would,  therefore,  demand  that  this  precaution  be 
insisted  upon  and  that  spectators,  as  well  as  assistants,  be  so  robed  that  the 
patient  is  fully  protected,  both  directly  and  indirectly,  from  infection  from 
this  source.  Such  garments  may  be  of  light  material,  muslin  or  linen  be- 
ing usually  preferred. 

Great  care  should  be  exercised  in  the  washing  of  all  garments  of  this 
character,  and  after  having  been  properly  laundered  they  should  be 
thoroughly  sterilized  just  before  the  operation,  that  any  infection  from  the 
laundry  room  may  be  destroyed.  Care  must  be  taken  that  all  are 
thoroughly  dried  after  sterilization. 

Suitable  Garments  for  the  surgeon  may  be  manufactured  from  twilled 
muslin  of  good  quality.  They  should  fit  loosely,  yet  cover  the  body  almost 
completely.  They  may  be  constructed  in  a  single  piece,  with  buttons  either 
in  front  or  back,  with  long  or  short  sleeves;  or  they  may  consist  of  two  gar- 
ments, shirt  and  trousers,  as  shown  by  figure  262.  The  latter  are  generally 
preferred  to  rubber  aprons,  sheets,  etc.,  because  they  admit  of  free  move- 
ment, and  are  cooler  and  more  comfortable. 

The  Assistant's  Gown,  exhibited  by  figure  263,  is  suitable  for  general 
hospital  work.  The  sleeves  are  of  good  length,  while  the  skirt  reaches 
almost  to  the  floor.  It  is  composed  of  a  single  piece  fastened  at  the  back, 
and  is  held  in  place  at  the  waist  by  suitable  bands. 

The  Male  Nurse's  Gown  may  be  somewhat  shorter  than  those  designed 
for  the  surgeon's  use ;  may  open  in  front  like  an  ordinary  shirt,  with  sleeves 
that  extend  either  to  the  wrist  or  only  to  the  elbow. 

The  Female  Assistant's  Gown  may  consist  of  a  long  garment  reaching 
nearly  to  the  floor,  with  closely  fitting  collar  and  having  the  waist  gathered 
at  the  skirt  band.  The  sleeves  will  be  better  if  they  extend  only  to  the 
elbow. 

133 


134 


APPAREL    EQUIPMENT    OF    SURGEONS,    NURSES,    ETC. 


Robb  advises  that  the  operator,  assistants,  and  nurses  wear  white  canvas 
shoes,  with  low  tops  and  rubber  soles.  He  argues  "that  they  are  clean  and 
noiseless,  and  by  their  employment  the  soiling  of  the  street  shoes  during  an 
operation  is  avoided.  They  can  be  easily  cleaned  by  washing  them  with 
water,  while  a  coating  of  white  clay  will  give  them  a  very  neat  appear- 
ance. ' ' 

The  Spectator's  Coat,  illustrated  by  figure  266,  is  one  of  the  many  pat- 
terns in  use  in  various  hospitals.  It  would  seem  advisable  that  spectators 
admitted  to  the  operating-room  should  remove  their  street  coats  and  replace 
them  with  a  special  sterilized  cotton  or  linen  garment.  A  number  of  such 
coats  could  be  provided  at  small  expense  and  form  part  of  the  parapher- 
nalia of  every  operating-room. 

The  Patient's  Robe,  shown  in  figure  267,  represents  one  of  the  more 
desirable  patterns. 


Figure  262.   Schachner's    Figure  263.    Assist- 
Operating  Suit.  ant's  Gown. 


Figure  264.     Baxter's  Rub-       Figure  265.  Surgeon's 
her  Apron,  Sleeveless  Rubber  Gown. 


The  addition  of  a  few  suits  for  the  use  of  patients  will  be  found  of  great 
advantage,  because  they  admit  of  extensive  and  lengthy  operations  on  the 
trunk  without  unnecessarily  exposing  the  patient  to  a  temperature  often- 
times debilitating. 

Such  a  garment  should  be  constructed  so  as  to  form  a  single  piece,  and 
may  include  legs,  arms,  and  in  some  cases  a  hood,  all  of  which,  with  the 
exception  of  the  last,  should  be  tightly  inclosed  at  the  extremities.  Meas- 
ures of  this  kind  may  occasionally  prevent  auto-infection,  particularly  when 
patients  are  struggling  under  the  influence  of  anesthetics.  The  only 
opening  generally  necessary  in  such  a  garment  is  one  extending  from  the 
neck  to  the  perineum,  special  dresses  being  employed  for  operations  on  the 
kidneys,  etc. 

Surgeons'  Aprons  are  usually  of  rubber  and  may  be  obtained  in  various 
forms  and  shapes.  Those  of  light  material  are  generally  worn  underneath 
the  operating  suit,  while  those  of  heavier  substance  are  worn  outside. 

Baxter's  Rubber  Apron,  as  sketched  in  figure  264,  illustrates  a  pattern 
intended  to  be  worn  outside  the  clothes  or  operating  suit.  It  is  provided 


SUITS,     GOWNS,    APRONS,     ETC. 


135 


with  a  solid  neck-piece  that  passes  over  the  head,  while   the   apron    fastens 
behind  with  suitable  strings. 

The  Sleeveless  Rubber  Gown,  displayed  in  figure  265,  is  larger,  does  not 
surround  the  neck  closely,  but  is  provided,  instead,  with  double  armholes. 
It  is  fastened  at  the  back  with  straps  and  buckles  or  with  suitable  strings. 


Figure  266.     Spectator's  Coat. 


Figure  26".     Patient's  Robe. 


Rubber  Gloves,  as  shown  by  figure  268,  form  a  convenient  article  in  the 
oiitfit  of  every  surgeon,  for  their  use  may  at  times  enable  the  operator  to 
personally  perform  some  act  that  without  them  would  necessitate  infection 
and  consequent  re-sterilization  of  the  hands.  Rubber  gloves  may  be 
sterilized  by  steam  or  boiling  water  in  the  same  manner  and  at  the  same 
time  as  the  dressings  or  instruments,  and  one  or  more  pairs  may  be  kept 
ready  for  use  in  emergency  cases.  With  them  the  surgeon  may.  handle 


TBUAX  GREENE  8  CO. 


Figure  268. 


Half  Long  Rubber 
Gloves. 


Figure  269.     Nurse's 
Rubber  Cap. 


Figure  270.    Rubber  Operating 
Sleeves. 


septic  articles  and  materials.  He  may  even  invade  septic  tissues,  the  only 
caution  necessary  being  to  know  in  every  instance  that  the  interior  of  the 
gloves  is  sterile. 

Rubber  Operating  Sleeves,  as  shown  in  figure  270,  are  occasionally  em- 
ployed because  of  their  convenience.  With  a  pair  of  these  sleeves  and  a 
pair  of  sterilized  gloves,  an  attendant,  even  with  unsterilized  hands,  could 
be  called  upon  to  assist  during  an  operation  without  the  necessity  of  taking 
the  time  required  for  mechanical  sterilization.  Of  course  this  would 
be  resorted  to  only  in  emergency  cases,  yet  a  complete  equipment  will 


136 


APPAREL    EQUIPMENT    OF    SURGEONS,   NURSES,    ETC. 


provide  for  cases  of  this  character.  They  are  composed  of  a  single  piece  of 
pure  gum  rubber,  fitting  closely  over  the  arm  from  the  wrist  to  a  point 
above  the  elbow.  Their  use  in  the  past  has  been  confined  almost  entirely  to 
obstetrical  work. 

Soft  Rubber  Caps,  as  illustrated  by  figure  269,  are  recommended  for  use 
at  the  operating  table  and  for  the  use  of  nurses  in  attendance  on  patients 
suffering  from  contagious  diseases.  They  consist  of  a  soft  rubber  cap 
supplied  with  a  band  fitting  closely  over  the  forehead  and  passing  backward, 
either  over  or  under  the  ears  as  desired.  The  body  of  the  cap  is  sufficiently 
loose  to  accommodate  the  hair  of  the  female  nurse,  and  as  contamination  of 
the  underlying  substance  is  impossible,  one  source  of  microbic  distribution  is 
therefore  avoided. 


Figure  271.    Senn's  Chatelaine  for  Nurses.  Figure  272.    Plain  Chatelaine  for  Nurses. 

Chatelaines. 

These  consist  of  a  set  of  instruments,  such  as  are  usually  employed  by 
nurses.  They  may  be  arranged  in  a  case,  or  each  connected  by  short  chains 
to  a  hook,  that  they  may  be  attached  to  a  belt  at  the  waist. 

Senn's  Chatelaine  for  Nurses  is  pictured  in  figure  271.  The  instruments 
comprised  in  this  set  are  divided  into  two  classes,  that  may  be  designated  as 
septic  and  aseptic.  The  ordinary,  or  instruments  that  may  to  a  certain 
extent  remain  septic,  are  in  plain  view  when  the  case  is  opened,  while 
those  that  should  be  rendered  and  maintained  sterile  are  attached  to  a 
special  card  or  plate  inclosed  in  a  small  pocket  specially  designed  to  keep 
them  separate  and  apart  from  the .  balance  of  the  instruments.  This 
special  set  of  aseptic  instruments  consists  of  a  plain,  blunt-pointed,  serrated 
dressing  forceps,  Kocher's  hemostatic  forceps,  straight  scissors,  director 
and  probe.  The  balance  of  the  instruments  consists  of  a  hypodermic 
syringe  in  a  metal  case  that  also  contains  four  bottles  of  tablets,  tape 
measure,  rubber  male  catheter,  metal  female  catheter,  fever  thermometer, 
nail  cleaner  and  curved  nail  scissors.  A  pair  of  heavy  bandage  shears 
are  attached  to  the  back  of  the  case,  where  they  are  held  in  place  by 
a  long  leather  loop  provided  for  this  purpose.  These  instruments  are  in- 


NURSES'    CHATELAINES.  137 

eluded  in  a  leather  case  4  inches  in  width  by  7  inches  in  length,  and 
may  be  attached  to  a  belt  by  a  suitable  leather-covered  clamp,  as  shown  in 
the  illustration. 

The  Plain  Chatelaine  for  Nurses,  illustrated  by  figure  272,  contains  a 
pair  of  straight  scissors,  plain  dressing  forceps,  hemostatic  forceps  with  ring 
handles,  fever  thermometer,  female  catheter,  and  two  silver  probes.  These 
instruments  are  arranged  in  a  neat  leather  case  supplied  with  flap  and 
catch,  the  whole  arranged  to  be  attached  to  a  belt  by  a  suitable  hook  or 
clamp. 


CHAPTER  VII. 


STERILIZATION. 


Sterilization  is  the  act  of  destroying,  removing  or  inhibiting  the  growth 
of  micro-organic  life.  It  is  principally  employed  in  surgery  as  a  prophy- 
lactic against  septic  infection,  and  is  applied  to  the  field  of  operation,  the 
persons  of  the  operators  and  assistants,  all  instruments  and  appliances;  in 
fact,  to  everything,  directly  or  indirectly,  brought  in  contact  with  tissues 
liable  to  microbic  invasion. 

As  it  has  been  fully  demonstrated  that  infection  rarely  takes  place  ex- 
cept by  contact,  it  follows  that  every  possible  precaution  must  be  taken  to 
guard  against  the  contamination  of  all  aseptic  substances  from  such  sources. 

The  imperative  necessity  for  strict  adherence  to  a  rigid  aseptic  discipline 
in  the  conduct  of  every  operation,  is  now  admitted  by  all  our  ablest  author- 
ities. No  rules  are  too  exacting,  no  process  too  tiresome,  no  labors  useless, 


Figure  273.    Tube  of  Surgical 
Soap. 


Figure  274.     Jar  of  Surgical 
Soap. 


Figure  275.     Can  of  Surgical  Soap. 


if,  by  their  careful  application,  sterilization  is  thereby  perfected.  Many 
methods  and  systems  of  sterilization  have  been  advocated  by  different 
authorities.  To  enumerate  all  known  or  advised  appliances  would  require 
more  space  than  is  at  our  disposal  for  this  purpose.  We  shall,  therefore, 
exclude  all  except  those  that  we  believe  have  proved  satisfactory  and  prac- 
tical, either  from  a  standpoint  of  efficiency  or  expense. 

The  systems  in  common  use  that  come  within  the  province  of  this  work 
are  mechanical,  chemical  and  thermal. 


MECHANICAL  STERILIZATION. 

This  consists  in  removing  by  force  all  infective  germs  and  extraneous 
matter  likely  to  contain  them.  It  may  usually  be  accomplished  by  wash- 
ing, scrubbing,  scouring,  scraping,  etc.  As  these  processes  are  more  or 
less  imperfect,  they  are  usually  supplemented  by  the  use  of  germicidal  solu- 

138 


MECHANICAL     STERILIZATION. 


139 


tions.  The  application  of  this  system  is  generally  restricted  to  the  hands 
and  arms  of  the  operator  and  assistants,  the  field  of  operation  on  the  patient, 
and  as  an  adjunct  to  other  methods  in  cleansing  instruments  and  apparatus. 
The  appliances  to  be  provided  besides  water  and  towels,  both  of  which 
should  be  previously  sterilized,  are:  Surgical  soap,  soap  box,  hand  brush, 
brush  box,  razor,  and  nail  cleaner. 

Surgical  Soap. 

The  Green  Soap  commonly  used  by  surgeons  is  more  or  less  infected 
with  micro-organisms,  particularly  those  of  a  pyogenic  nature. 

Not  only  is  this  preparation  frequently  compounded  from  animal  fats 
contaminated  with  hosts  of  bacteria,  but  in  its  manufacture  no  attempt  is 
made  to  either  prepare  it  aseptically  or  to  store  it  in  sterilized  packages. 

The  too-common  practice  among  surgeons  of  attempting  to  secure  me- 
chanical sterilization  of  the  hands,  forearms  and  site  of  operation  by  the 
aid  of  a  soap  loaded  with  bacteria,  should  be  discontinued,  and  in  its  place  a 
preparation  of  known  purity,  stored  in  sterilized  packages,  should  alone  be 
used. 

A  surgical  soap  of  high  quality  may  be  manufactured  by  saponifying 
linseed,  cotton  seed,  or  pure  olive  oil  with  soda  ash  or  caustic  soda.  While 
in  a  liquid  state,  it  may  be  poured  into  any  desired  container,  the  latter 


Figun 


Flint  Glass  Soap  Box. 


Figure  277.     Ordinary  Vege 
Hand  Brush. 


having  been  previously  sterilized.  For  use  in  operations  in  the  office  and 
out  of  the  hospital,  a  properly  prepared  compressible  tube,  holding  about 
four  ounces,  would  appear  to  be  a  desideratum.  Larger  quantities  should 
be  stored  in  glass  jars  provided  with  tightly  fitting  covers. 

Soap  Boxes. 

These  may  be  procured  of  ordinary  patterns,  granite,  glass  and  porce- 
lain being  employed  in  their  manufacture.  One  or  more  should  form  part 
of  the  armament  of  every  surgeon's  wash-stand. 

The  Glass  Soap  Box  shown  in  figure  276  is  provided  with  a  false  per- 
forated bottom  to  permit  of  drainage.  They  may  be  obtained  in  various 
sizes,  the  usual  pattern  being  about  4  inches  wide,  7  inches  long  and 
4  inches  high. 

Hand  Brushes  and  Brush  Boxes 

Hand  Brushes  may  be  either  of  bristle  or  vegetable  fiber.  While  bris- 
tle brushes  are  better  for  scrubbing  purposes,  they  cannot  be  sterilized  with- 
out damage  to  the  bristle  substance.  For  this  reason  grass  brushes  are 


140 


STERILILATION. 


almost  universally  employed.  They  can  be  purchased  so  cheaply  in  dozen 
or  gross  lots  that  after  having  been  once  employed  they  may  be  destroyed 
and  fresh  ones  substituted.  They  may  be  sterilized  by  boiling  for  a  few 
minutes  in  plain  water  or  in  an  alkaline  or  antiseptic  solution  of  soda. 
Many  substitutes  for  brushes  have  been  suggested,  but  thus  far,  we  believe, 
nothing  has  been  found  equally  as  effectual  in  the  removal  of  filth  accumu- 
lations from  the  grooves,  creases  and  folds  of  the  skin  and  in  the  rubbing 
away  of  the  thickened  and  hypertrophied  epidermis  often  found  on  the 
hands  and  feet  of  patients.  Brushes  of  good  size  and  without  handles  are 
usually  preferred.  Small  brushes  require  more  time  and  are  not  so  effective. 
The  Ordinary  Hand  Brush  is  exhibited  by  figure  277,  while  figure  278 
illustrates  a  German  design  in  which  the  brush  is  fastened  by  screws  to  the 
under  side  of  the  cover  of  a  glass  box.  According  to  Schimmelbusch, 
"Upon  every  physician's  wash-stand  there  should  be  a  receptacle  containing 
a  brush  immersed  in  sublimate  solution,  as  a  necessary  aid  to  thorough 
cleansing. ' '  While  this  author  does  not  recommend  any  particular  form  of 
"receptacle,"  this  design  seems  to  meet  every  indication.  The  brush 
fastened  to  the  cover  may  be  suspended  in  the  liquid,  and  as  the  cover  pro- 


Figure  278.  Individual  Brush  Box, 
Brush  Fastened  to  Cover. 


Figure  279.    Glass  Brush  Box 
with  Cover. 


Figure  280.     Open  Glass 
Brush  Box. 


tects  the  brush-back  from  air  and  hand  infection,  the  combination  seems  a 
useful  one.  They  can  be  procured  in  common  pressed  glass  at  a  small 
expense.  Various  colored  boxes  can  be  purchased,  so  that  if  more  than  one 
solution  be  used  there  may  be  no  difficulty  in  selecting  the  one  wanted. 

The  Glass  Brush  Box,  with  cover,  as  portrayed  in  figure  279,  is  one  in 
which  it  is  intended  to  keep  two  or  more  brushes  either  dry  or  in  solution. 
Usually  they  will  hold  from  four  to  six  brushes. 

The  Glass  Brush  Box,  depicted  in  figure  280,  is  designed  to  be  sus- 
pended from  the  wall  forming  the  back  of  the  sink.  It  is  large  enough  to 
hold  from  four  to  six  brushes. 

Razors. 

These  are  required  in  most  cases  when  external  incisions  are  necessary. 
They  are  not  only  employed  for  the  removal  of  any  hair  immediately  sur- 
rounding the  field  of  operation,  but  to  assist  in  scraping  away  devitalized 
epithelial  cells,  the  natural  abiding-place  of  pyogenic  microbes.  They  are 
of  two  varieties:  Folding  and  solid. 

Folding  Razors  are  the  ordinary  form,  such  as  are  in  common  use.  For 
surgical  work,  however,  a  separable  pattern,  one  that  can  be  cleansed  in 
all  its  parts,  is  advised. 

The  Razor  exhibited  in  figure  281  is  provided  with  a  handle,  which  may 
be  separated  into  three  parts  and  the  blade  thereby  detached.  This  admits 


MECHANICAL    STERILIZATION. 


141 


of  thorough  cleansing  and  constitutes  a  desirable  pattern.  It  is  not  only 
serviceable  in  the  operating-room,  but  forms  a  convenient  design  for  the 
emergency  bag. 

Solid  Razors  are  those  constructed  of  one  piece  of  metal. 


Figure  281.    Razor  with  Separable  Handle  for  Sterilizing. 

Robb's  Razor,  as  traced  in  figure  282,  is  manufactured  from  a  single 
piece  of  steel.  As  it  possesses  no  joints,  catches  or  rivets,  it  may  easily  be 
sterilized  like  any  other  instrument.  A  plain  case  covering  the  blade  pro- 
tects the  edge  from  contact  or  injury. 

Nail  Cleaners. 

These  are  employed  to  remove  the  deposits  from  under  and  around  the 
finger-nails.  While  ivory  .and  flat,  well-smoothed  wood  toothpicks  answer 
in  cases  where  there  is  danger  of  injuring  the  matrix  by  a  harsher  instru- 
ment, metal  nail  cleaners  should  form  part  of  the  disinfecting  outfit. 

The  Nail  Cleaners  pictured  in  figures  283  and  284  exhibit  two  of  the 
most  common  forms  in  use. 


Figure  282.    Robb's  Solid  Razor. 

The  first  is  manufactured  with  a  long  handle,  while  the  second  is  a  solid 
steel  pattern,  with  a  cleaner  on  one  end  and  burnisher  on  the  other.  The 
bodies  of  both  patterns  are  cut  into  files. 

While  ordinary  nail  files  have  been  long  in  use  for  cleaning  the  finger- 
nails, the  file  portion  of  the  instrument  is  objected  to  by  some  surgeons 
because  its  use  leaves  a  roughened  surface  upon  the  edge  of  the  nail.  It 


Figure  283.    Nail  Cleaner. 


Figure  284.    Plain  Steel  Nail  Cleaner. 


also  lacerates  the  external  layers  of  the  skin  whenever  brought  in  con- 
tact with  it. 

Braatz'  Nail  Cleaner,  as  portrayed  in  figure  285,  consists  of  a  blade  of 
brass  or  other  metal  of  similar  hardness,  the  face  or  scraping  surface  of 
which  is  oblique  and  beveled.  This  presents  a  fine  point  and  edge,  which 
may  be  used  to  quickly  and  efficiently  clean  an  inner  nail  surface.  The 
blade  is  hinged  within  a  loop  handle,  so  that  when  not  in  use  the  edge  may 
be  folded  within  the  loop,  and  thus  protected  from  injury. 


142  STERILIZATION. 

CHEMICAL    STERILIZATION. 

This  consists  in  the  destruction,  or  arrest  of  development  of  disease 
germs,  by  bringing  certain  chemicals  in  contact  with  them. 

Chemical  sterilization  may  be  secured  by  application  of,  or  saturation 
with  liquids,  or  by  penetration  with  some  form  of  gas.  The  latter  process 
is  sometimes  called  fumigation. 

The  chemical  selected  must  depend  on  the  physical  characteristics  of  the 
article  to  be  disinfected,  the  peculiar  form  of  microbe  to  be  destroyed,  and 
the  nature  of  the  matrix  in  which  they  are  involved.  For  disinfecting  the 
hands  and  arms  of  operators  and  assistants,  liquid  chemicals  used  singly, 
two  or  more  consecutively,  or  in  some  combination,  are  usually  employed 
as  an  aid  to  mechanical  methods. 

Chemical  sterilization  is  not  generally  applicable  to  the  disinfection  of 
surgical  instruments.  Usually  if  the  chemical  be  of  sufficient  strength  to 
destroy  all  infective  agents,  it  can  not  be  tolerated  by  the  hands  of  the  sur- 
geon or  assistant.  Bichloride  of  mercury  soon  corrodes  and  damages  steel 
instruments,  so  that  in  selecting  a  chemical  germicide  for  this  purpose,  the 
most  powerful  one  must  be  excluded.  Further  than  this,  too  much  resist- 
ance is  offered  by  infected  material  inclosed  in  crevices  or  located  beneath 
layers  of  fat  or  dirt,  to  say  nothing  of  the  time  required  to  secure  surgical 
asepsis  and  the  expense  of  the  process. 


Figure  285.    Braatz'  Nail  Cleaner. 

The  substances  employed  in  chemical  sterilization,  although  occasionally 
required  in  a  strength  sufficient  for  disinfecting  purposes,  are  usually  called 
antiseptics.  As  it  is  not  within  the  scope  of  this  work  to  enter  into  a  dis- 
cussion of  the  merits  or  demerits  of  chemicals  utilized  for  surgical  pur- 
poses, we  shall  make  mention  of  only  a  limited  number,  confining  our- 
selves to  those  in  most  common  use,  describing  in  connection  with  each, 
such  containers  as  have  been  found  valuable  for  their  storage  and  trans- 
portation. 

Those  selected  consist  of:  Corrosive  sublimate,  carbolic  acid,  boric 
acid,  salicylic  acid,  iodoform,  carbonate  of  soda,  lysol,  ether,  alcohol,  sulphur, 
and  formaldehyde. 

Corrosive  Sublimate.  This  is  a  white  crystalline  substance,  usually  in 
powdered  form.  As  it  is  easily  decomposed  by  contact  with  metals,  care 
must  be  exercised  in  handling  and  using  it.  It  cannot  be  stored  in  metal 
vessels  either  in  powder  or  solution,  nor  can  it  be  used  for  sterilizing  steel 
surgical  instruments.  Owing  to  its  violent  poisonous  properties,  great  care 
is  necessary  to  accurately  subdivide  a  given  quantity.  It  is  advised  that 
it  be  purchased  and  kept  in  tablet  form,  thus  securing  safety  in  handling 
and  uniformity  of  strength  in  solutions. 

The  Hard  Rubber  Bottle  depicted  in  figure  290  is  of  a  pattern  constructed 
for  use  in  the  medical  and  surgical  chests  devised  by  M.  O.  Terry,  of  Utica, 
N.  Y. ,  for  military  use.  The  walls  are  of  sufficient  weight  to  avoid  break- 
age, while  a  proper  label,  "Cor.  Sub.  7^  G.  Poison,"  is  plainly  stamped  in 
the  cover.  While  the  ordinary  glass  bottle  will  answer  for  the  hospital  and 


CHEMICAL    STERILIZATION. 


143 


surgical  room,  the  surgeon  who  operates  outside  of  his  office  or  hospital  will 
find  the  hard  rubber  container  more  desirable  for  transportation. 

Carbolic  Acid  in  its  pure  form  is  a  white,  colorless,  volatile,  crystalline 
mass,  dissolving  at  95  °  F.  It  may  be  kept  permanently  in  a  fluid  form  by 
the  addition  of  5  per  cent,  (i  120)  of  distilled  water.  This  forms  a  convenient 
preparation  for  stock  and  transportation.  It  may  be  approximately  made 
by  adding  6y2  drams  of  distilled  water  to  i  Ib.  of  the  crystallized  acid,  dis- 
solved by  gentle  heat. 

It  may  be  purchased  in  crystalline  form,  in  packages  of  almost  any  size. 
When  prepared  by  the  surgeon,  it  should  be  stored  in  strong  bottles.  Those 
with  ordinary  cork  or  glass  stopper  will  answer. 

The  Metal  Covered  Bottle,  traced  in  figure  286,  exhibits  a  desirable  form 
of  package  in  which  to  carry  carbolic  acid,  styptics,  collodions  and  other 
fluids.  It  consists  of  a  glass  stoppered  bottle,  inclosed  in  a  metal  case,  the 
latter  in  two  parts,  connected  by  a  threaded  screw.  Each  case  is  con- 
structed so  that  it  is  adjustable  to  bottles  of  different  heights,  that  the  cap 


Figure  286.     Metal  Cover  Be 


Figure  287.    Screw  Cap    Figure  288.    Author's 
Safety  Bottle.  Aluminum  Bottle. 


may  at  all  times  be  screwed  firmly  down  upon  the  glass  stopper,  thus  secur- 
ing the  latter  from  being  loosened  during  transportation.  They  are  usually 
of  four  sizes:  i,  2,  4  and  8  ounces. 

The  Aluminum  Bottle,  illustrated  in  figure  288,  was  designed  by  the 
author  for  use  in  the  army  medical  chest  devised  by  Senn,  as  exhibited 
by  figure  2213.  It  is  spun  from  a  single  piece  of  aluminum,  and  is  supplied 
with  a  metal  clamp  for  holding  the  cork  in  place.  This  clamp  is  attached 
by  a  chain  to  the  neck  of  the  bottle,  and  affords  a  flat  surface  upon  which 
may  be  stamped  a  proper  label  of  the  bottle  contents.  They  are  manufact- 
ured in  three  sizes:  2,  4  and  8  ounces. 

The  Screw  Cap  Safety  Bottle,  portrayed  in  figure  287,  has  extra  heavy 
walls  and  a  ground  glass  stopper.  The  latter  is  held  in  place  by  a 
deep  metal  cap  that  is  constructed  with  a  screw  fitting  closely  upon  a 
thread  blown  in  the  neck  of  the  bottle.  This  pattern  is  suited  for  use  in 
the  construction  of  medicine  cases,  for  service  in  emergency  bags,  and  for 
army  medical  pouches. 


144 


STERILIZATION. 


Boric  Acid  is  a  crystallized  salt,  in  colorless  scales,  usually  employed  in 
surgery,  however,  in  an  impalpable  powder. 

Salicylic  Acid  is  also  usually  applied  to  wound  surfaces  in  powdered 
form.  It  should  be  remembered  that  this  chemical,  even  in  weak  solution, 
corrodes  steel  instruments. 

lodoform,  also  in  powder  form,  like  those  previously  mentioned,  may  be 
kept,  carried  and  distributed  into  or  over  a  wound  by  means  of  boxes 
called  dusters.  They  are  usually  of  the  "pepper-box  style, ' '  of  metal,  glass 
or  hard  rubber. 

The  lodoform  Box,  illustrated  in  figure  291,  shows  a  glass  bottle  to 
which  is  attached  a  hard  rubber  sprinkling  cap.  Its  only  advantages  are 
that  it  costs  little  and  that  the  quantity  of  powder  in  the  bottle  can  always 
be  determined  by  sight. 

The  Hard  Rubber  lodoform  Box,  outlined  in  figure  292,  exhibits  a 
German  pattern  manufactured  entirely  from  hard  rubber.  The  lower  end 
or  cap  is  removable  for  replenishing  the  contents.  The  bowl-shaped  cover, 
or  top,  is  double,  both  parts  having  several  rows  of  small  holes  arranged 
opposite  each  other.  While  the  inner  part  is  fixed,  the  outer  one,  by  means 


Figure  289.    All  Metal  lodo- 
form Box. 


Figure  290.    Hard 
Rubber  Bottle. 


Figure  291.    Greene's 
lodoform  Box. 


Figure   292.     lodoform 
Box  with  Revolv- 
ing Top. 


of  a  pin  and  slot,  may  be  made  to  revolve  for  a  short  distance.  When  used 
as  a  sprinkler,  the  outer  part  is  moved  until  the  holes  in  both  parts  are  in 
apposition ;  after  use  the  openings  are  closed  by  turning  the  cover  back. 

The  All  Metal  lodoform  Box,  as  exhibited  by  figure  289,  illustrates  a 
desirable  pattern  for  the  application  of  iodoform  or  other  sterilizing  agents 
in  powder  form. 

It  consists  of  a  metallic  cylinder,  provided  with  a  screw  cup-shaped 
cover,  the  latter  having  a  double  wall,  the  inner  wall  surface  upon  one  side 
containing  a  number  of  perforations.  The  outer  portion  revolving  around  the 
inner  is  provided  with  a  slot  or  opening  of  the  same  size  as  that  occupied 
by  the  perforations  previously  referred  to.  By  turning  the  outer  cylinder 
to  the  right  or  left,  any  inclosed  powder  may  be  prevented  from  escaping 
through  the  perforations. 

Carbonate  of  Soda  is  largely  employed  in  a  one  to  two  per  cent,  solution 
for  washing  or  boiling  surgical  instruments  and  other  appliances.  It  may 
be  transported  in  glass  or  tin  containers. 


CHEMICAL     STERILIZATION.  145 

Absolute  Alcohol  and  Ether  may  be  transported  in  ordinary  bottles 
with  plain  corks. 

Sulphur.  The  active  principle  of  this  chemical  when  used  for  disinfect- 
ing purposes  is  sulphurous  acid  gas,  generated  by  burning  the  sulphur. 
The  most  satisfactory  method  tor  producing  this  gas'is  by  the  aid  of  sulphur 
candles.  These,  as  evidenced  in  figure  293,  are  manufactured  by  inserting 
wicks  in  the  center  of  a  can  of  melted  sulphur,  in  order  that  the  sulphur 
may  be  ignited  and  burned  the  same  as  an  ordinary  candle.  This  method 
is  now  employed  only  for  the  fumigation  of  rooms  that  have  become  infected 
by  contagious  diseases. 

Formaldehyde  Gas.  This  powerful  germicide,  discovered  by  Von  Hoff- 
man in  1867,  was  of  little  use  until  Blume  and  Loew,  in  1888,  demonstrated 
its  wonderful  properties.  Since  that  time  it  has  rapidly  grown  in  favor, 
and  for  certain  purposes  it  occupies  a  front  rank  among  positive  and  certain 
disinfectants.  It  possesses  the  properties  of  ready  diffusibility,  great 
powers  of  penetration  and,  even  when  highly  diffused,  is  quickly  destructive 
of  all  pathogenic  micro-organisms,  whatever  their  condition.  It  is  formed 
by  the  oxidation  of  methyl  alcohol  in  a  suitably  constructed  apparatus. 
Its  generation  is  practically  a  process  of  retarded  combustion.  It  may  be 
successfully  employed  for  disinfecting  large  areas,  such  as  theaters,  halls, 


Figure  293.    Sulphur  Candles  or  Torches. 


hospital  wrards,  railroad  cars,  residences,  private  rooms,  etc.  For  dressings 
and  similar  fabrics  it  furnishes  means  for  certain  surgical  sterilization.  It 
is  not  well  adapted  for  disinfecting  steel  instruments  on  account  of  the 
rapid  oxidation  that  ensues  when  the  gas  is  brought  in  contact  with 
unprotected  iron  or  steel.  As  it  unites  freely  with  water,  and  as  it  may  be 
produced  as  solid  polymerized  formaldehyde,  it  may  be  obtained  in  concen- 
trated form.  Manufacturers  have  placed  on  the  market  various  proprietary 
articles,  known  as  formal,  formalin,  formaldene,  etc.,  most  of  which 
represent  either  a  40  per  cent,  concentrated  aqueous  solution  of  the  gas  or 
the  pure  paraformaldehyde,  the  latter  also  called  troxymethylene.  When 
it  is  understood  that  one  part  of  the  40  per  cent,  solution  to  2,500  of  water 
will  destroy  pathogenic  bacteria  in  one  hour,  the  strength  of  the  concen- 
trated preparations  will  at  once  be  appreciated.  It  may  be  obtained  in 
solid  form  in  powder,  or  in  the  form  of  pastils,  a  common  form  of  the  latter 
usually  representing  2^  grammes  of  the  40  per  cent,  fluid  preparation. 

For  purposes  of  disinfection  there  are  two  methods  of  securing  this  gas: 
Generation  by  oxidation  of  methyl  alcohol,  and  liberation  from  concentrated 
preparations. 

Direct  Generation  of  this  gas  may  be  secured  by  the  combustion  of  wood 
alcohol  in  a  suitable  lamp  or  burner.     Among  the  many  forms  of  gener- 
ators, wre  exhibit  those  that  represent  useful  and  distinct  types. 
10 


146 


STERILIZATION. 


Hollister's  Formaldehyde  Sterilizer,  as  exhibited  in  figure  294,  consists 
of  a  metallic  reservoir,  supplied  with  a  wick  that  delivers  the  methylic 
vapor  to  the  dome,  where,  by  means  of  a  draught  arrangement,  it  is  mixed 
with  the  air-oxygen  necessary  for  its  perfect  decomposition.  The  upper 
dome  opening  is  fitted  with  a  combination  decomposing  screen,  which  when 
lighted  burns  with  an  incandescent  glow.  A  suitable  chimney  completes 
the  apparatus.  As  there  is  no  flame,  combustion  is  secured  with  a  limited 
quantity  of  fluid. 

Moffatt's  Formaldehyde  Generator  consists  of  a  metallic  lamp  arranged 
with  one  or  more  burners  of  special  construction.  The  arrangement  is  such 
that  by  means  of  a  suitable  burner  and  chimney,  partial  combustion  of 
wood  or  methyl  alcohol  may  be  secured.  By  means  of  a  wick,  all  of  the 
spirits  placed  in  the  generator  may  be  conveyed  to  the  burner,  and  the 
apparatus  continues  to  generate  gas  until  the  alcohol  is  exhausted.  It  is 
claimed  that  each  pint  of  wood  alcohol  will  generate  with  this  apparatus  a 
sufficient  quantity  of  gas  to  destroy  all  pathogenic  germs  in  3,000  cubic  feet 
of  space.  Three  sizes  have  been  placed  on  the  market,  with  one,  four  and 


Figure  294.    Hollister's  Formaldehyde 
Generator. 


Figure  295.    Formaldehyde  Disinfect- 
ing Chamber. 


twelve  burners  each,  the  larger  forms  being  applicable  where  large  areas 
are  to  be  disinfected. 

Liberation  from  Concentration  consists  in  submitting  the  gas  in  some 
concentrated  form  to  a  degree  of  heat  sufficient  for  its  resolution.  When 
in  the  form  of  a  solution,  this  may  be  accomplished  in  a  similar  manner  to 
the  generation  of  steam.  Whether  in  liquid  or  solid  form,  heat  is  all  that 
is  required  for  its  liberation.  Many  of  the  appliances  employed  with  liquid 
concentrations  are  called  autoclaves. 

Scherring's  Lamps,  as  delineated  in  figures  296  and  297,  are  constructed 
for  vaporizing  formaldehyde  pastils. 

These  pastils  are  made  from  paraform,  a  solid  acid  fonn  of  the  gas. 
The  small  apparatus  consists  of  an  alcohol  lamp  with  suitable  burner  and 
chimney.  The  latter  consists  of  a  sheet  iron  mantle  or  cylinder,  with  a 
small  cup-shaped  container  in  which  the  pastils  are  placed.  The  upper  end 
of  the  vessel  is  provided  with  a  number  of  slits,  through  which  the  gases 


CHEMICAL   STERILIZATION.  147 

formed  by  the  combustion  of  the  alcohol  (carbonic  acid  and  watery  vapor) 
escape.  In  their  passage  through  this  vessel,  these  vapors  of  combustion 
are  thoroughly  mixed  with  the  formalin  vapor  generated  by  the  heating  of 
the  formalin  pastils. 

The  lamp  is  claimed  to  be  perfectly  safe ;  if  only  about  half  filled  with 
alcohol,  it  may  be  safely  left  in  a  room  until  the  alcohol  has  burned  out. 

The  large  apparatus  shown  by  figure  297,  in  general  form  consists  of  a 
large  metallic  cylinder  with  a  short  inverted  funnel  attached  to  its  lower 
margin.  The  burner  in  this  apparatus  is  much  larger,  and  the  receiver 
for  the  pastils  is  of  proportionate  size. 

It  is  made  of  brass,  with  a  glass  chimney  resting  upon  the  reservoir. 
The  upper  part  of  the  cylinder  supports  two  receptacles,  the  upper  designed 
for  deodorization,  and  the  lower  for  disinfection. 

John's  Formaldehyde  Liberator,  as  exhibited  by  figure  298,  is  intended 
for  the  sterilization  of  surgical  instruments,  dressings,  gowns,  nursing  bot- 
tles, etc.  It  consists  of  a  small  boiler  with  support  and  lamp,  the  whole  be- 
ing similar  in  construction  to  the  ordinary  forms  of  steam  atomizers.  It  is 
employed  for  liberating  the  gas  from  a  40  per  cent,  solution,  requiring  but 
one  ounce  of  the  latter  for  completely  sterilizing  the  chamber  contents. 
It  is  simple  in  construction,  impossible  to  explode,  and  certain  in  its  action. 


Figure  290.     Scherring's  Formalin  Lamp,  Figure  29T.    Scherring's  Formalin  Disinfector  and 

for  Household  Use.  Deodorizing  Lamp. 

An  ordinary  alcohol  lamp  is  used  to  liberate  the  gas.  As  it  is  necessary 
with  each  charge  to  add  a  small  quantity  of  chloride  of  calcium  to 
prevent  polymerization,  an  opening  of  sufficient  size  for  cleansing  is 
necessary.  In  the  apparatus  above  shown  this  is  effected  by  means  of 
a  screw  joint  in  the  top  of  the  dome.  The  lamps  ordinarily  employed 
are  a  simple  form  of  wickless,  high-test  petroleum  burners  that  not  only 
heat  quickly  but  are  also  economical  and  safe. 

The  apparatus  shown  in  the  illustration  is  supplied  with  a  dome  6 
inches  in  diameter  and  9  inches  high,  with  a  capacity  for  disinfecting  15,000 
cubic  feet. 

The  Formaldehyde  Autoclave,  shown  in  figure  299,  represents  an  appara- 
tus somewhat  modified  from  that  devised  by  Trillat  and  those  advised  by 
other  French  scientists.  It  is  claimed  that  the  best  results  in  the  liberation 
of  formaldehyde  gas  can  be  obtained  only  under  a  pressure  of  from  twenty- 
five  to  fifty  pounds  to  the  square  inch.  This  apparatus  consists  of  a  reservoir 
in  dome  form,  the  bottom  being  concave  externally.  This  is  necessary 
in  order  that  the  instrument  may  withstand  the  necessary  pressure  and  at 
the  same  time  permit  the  use  of  a  strong  heating  apparatus. 


148 


STERILIZATION. 


The  reservoir  is  provided  with  a  water  gauge  by  which  the  quantity  of 
contained  fluid  may  at  all  times  be  noted.  The  dome  is  surmounted  by  a 
pressure  gauge,  safety  valve  and  cock.  The  latter  may  be  arranged  in 
connection  with  a  controlling  valve  of  any  desired  strength.  This  may  be 
so  arranged  that  gas  will  not  issue  from  the  instrument  until  the  desired 
pressure  is  obtained,  and  will  continue  to  pass  out  only  while  the  pressure 
is  at  about  the  given  point.  Such  reservoirs  are  usually  coated  with  pure 
tin,  that  they  may  resist  any  corroding  action. 

The  Sanitary  Formaldehyde  Resolver,  as  set  forth  in  figure  300,  consists 
of  a  receiver,  the  bottom  of  which  is  connected  with  a  shallow  circular  de- 
composing chamber,  arranged  in  such  a  manner  that  it  may  be  heated  to 
any  desired  degree  by  means  of  a  Swedish  lamp.  Communication  between 
the  receiver  and  heating  chamber  is  controlled  by  means  of  a  valve,  the  lat- 
ter terminating  at  the  top  of  the  receiver  in  a  suitable  handle,  by  means  of 
which  it  may  be  operated.  A  piece  of  copper  pipe  and  elastic  hose  conveys 
the  liberated  gas  to  any  desired  point.  A  large  opening  in  the  receiver  per- 
mits the  introduction  of  a  40  per  cent,  or  other  solution,  from  which  the  gas  is 
liberated.  In  its  operation,  the  decomposing  chamber  is  intensely  heated, 
after  which  the  valve  is  opened,  causing  an  inward  flow  of  a  small  stream  of 


Figure  298.    John's  Formaldehyde  Liberator. 


the  solution.  This  is  instantly  decomposed,  and  the  free  gas  passes  out 
through  the  elastic  hose.  By  this  arrangement  the  gas  is  liberated  without 
pressure  and  any  danger  of  explosion  avoided.  It  is  particularly  adapted  to 
apartment  disinfection. 

For  disinfecting  small  articles,  some  form  of  chamber  or  cupboard,  pro- 
vided with  means  for  retaining  the  gas  in  contact  with  the  articles  to  be 
sterilized,  is  necessary. 

The  Formaldehyde  Sterilizing  Chamber,  outlined  in  figure  295,  is  a 
strong  copper  chamber,  the  inside  of  which  is  subdivided  into  drawers 
with  wire  gauze  bottoms.  The  front  is  furnished  with  a  door,  separated 
from  the  drawer  fronts  by  an  air  space  2  inches  in  depth,  this  space  con- 
necting directly  with  the  pipe  which  extends  to  the  flue  or  chimney.  The 
outlet  at  the  top,  connecting  by  a  pipe  with  a  chimney,  is  double  and  con- 
trolled by  a  damper  in  such  a  manner  that  the  generated  gas  will  nearly  all 
remain  in  the  sterilizer  until  liberated.  Any  surplusage  or  leakage  that 
may  occur  through  the  drawer  fronts  will  be  conducted  upward  through  the 
air  space  previously  referred  to.  A  small  ventilator  near  the  bottom  of  the 


CHEMICAL    STERILIZATION. 


149 


chamber  front  permits  the  entrance  of  fresh  air.  When  in  operation,  it  is 
impossible  for  gas  to  escape  from  the  sterilizer  into  the  apartment. 

When  the  operator  desires  to  withdraw  instruments  or  dressing,  it  is 
necessary  only  to  turn  the  damper  at  the  top  and  open  the  ventilator,  when 
the  gas  will  immediately  be  replaced  with  fresh  air. 

This  apparatus  is  adapted  for  the  sterilization  of  ligatures,  dressings, 
catheters,  etc. 


Figure  299.    Modified  Trillat's  Formaldehyde 
Autoclave. 


Figure  300.     Sanitary  Formaldehyde 
Resolver. 


Scherring's  Formalin  Sterilizer,  as  sketched  in  figure  301,  comprises  a 
chamber  supplied  with  perforated  metal  racks,  and  closed  by  a  suitable  door. 
It  is  intended  for  use  with  the  small  generator  described  on  page  147. 
While  special  sterilizers  of  any  desired  size  may  be  procured,  the  regular 


Figure  301.    Scherring's  Formalin  Sterilizer. 

pattern  is  18  inches  in  width  by  \\y2  inches  in  height.  They  are  intended 
for  the  sterilization  of  instruments,  dressings,  towels,  robes,  and  other  fabrics 
employed  in  the  operating  room.  While  they  may  be  constructed  of  tin  or 
copper,  the  former  is  usually  employed. 


150 


STERILIZATION. 


THERMAL  STERILIZATION. 

This  consists  in  subjecting  infected  articles  to  a  degree  of  heat  sufficient 
to  destroy  all  forms  of  microbic  life.  Heat  is,  without  question,  our  best 
and  most  reliable  germicide.  Its  action,  when  properly  applied,  is  certain, 
and  it  secures  perfect  results  with  a  minimum  expense. 

The  methods  employed  are :  Flame  contact,  hot  air,  steam  and  boiling. 

Flame  Contact. 

This  is  only  applicable  to  small  instruments  and  consists  in  placing  the 
instrument  in  the  flame  of  a  Bunsen  burner,  alcohol  lamp,  candle,  gas  jet, 
or  similar  blaze.  The  first  two  are  the  better  because  of  the  round  form 
and  larger  area  of  the  flame,  and  because  the  heat  produced  is  not  con- 
fined to  so  limited  a  space.  Plain  steel  instruments,  such  as  sounds,  probes, 
directors,  etc. ,  may  be  rendered  sterile  by  dipping  them  in  alcohol  and  then 
burning  it  off.  This  method  is  little  used  and  only  in  emergency  cases, 
such  as,  for  instance,  sterilizing  hypodermic  needles,  probes  metal  cathe- 
ters, etc. 


Figure  302.    Plain  Hot  Air  Sterilizer. 


Figure  303.    German  Pattern  Hot  Air 
Sterilizer. 


Care  must  be  taken  in  such  cases  not  to  heat  the  instrument  sufficiently 
to  destroy  the  temper  or  melt  the  solder,  which  may  be  easily  done. 

Hot  Air  (Dry  Heat)  Sterilization. 

Sterilization  by  dry  heat  is  effected  by  passing  a  current  of  hot  air  through 
or  around  the  articles  to  be  disinfected.  Hot  air,  while  it  may  be  utilized 
as  an  efficient  germicide,  is  inferior  to  either  steam  or  hot  water  for  general 
purposes.  The  degree  of  heat  necessary  to  destroy  pyogenic  forms  of  micro- 
bic life  by  this  method  is  about  212°  Fahrenheit,  continued  for  one  and 
one-half  hours.  Anthrax  and  some  other  forms  of  pathogenic  bacteria  and 
their  spores  will,  however,  resist  a  temperature  of  284°  Fahrenheit,  unless 
it  be  maintained  for  several  hours.  This  process,  once  quite  popular,  is 
now  little  employed,  having  been  replaced  by  methods  which  are  more 
reliable  and  occupy  less  time.  From  twenty  to  thirty  minutes  are  necessary 
to  secure  the  proper  amount  of  heat,  and  tnis  must  be  maintained  for  from 
one  and  one-half  to  three  hours.  Instruments  successively  sterilized  by 


THERMAL    STERILIZATION. 


151 


this  method  soon  become  so  rusty  as  to  be  unfit  for  use,  due  probably  to 
the  precipitation  of  moisture  caused  by  the  sudden  heating  and  cooling  of 
the  sterilizer  and  contents.  Small,  finely  tempered  instruments  become 
soft  and  worthless,  and  general  destruction  of  cutting  edges,  springs,  plating, 
etc.,  soon  ensues.  As  it  is  impossible  to  so  pack  a  sterilizing  chamber  that 
it  will  offer  at  all  points  an  equal  amount  of  resistance  to  passing  air  cur- 
rents, it  follows  that  as  these  currents  will  seek  the  routes  least  obstructed, 
a  variation  of  temperature  in  different  portions  of  the  sterilizer  will  occur 
and  imperfect  disinfection  will  result.  Further,  in  many  patterns,  a  far 
higher  temperature  is  reached  in  the  bottom  than  at  the  top  of  the  chamber, 
and  if  the  temperature  at  the  top  be  raised  to  a  sufficient  height  to  produce 
absolute  sterility  of  contents,  the  excessive  heat  nearest  to  the  flame  will 
often  damage  the  inclosed  contents.  These  complications  preclude  the 
employment  of  this  system  for  sterilizing  dressings,  clothing  and  similar 
substances.  It  may  be  employed  for  small  quantities  of  dressings  and 
similar  fabrics,  or  in  cases  where  only  packages  of  a  uniform  size  and  shape 
are  inclosed.  This  latter  exception  enabled  Benckiser  and  Reverdin  to  first 
successfully  employ  this  method  in  the  sterilization  of  catgut. 


Figure  304.    Boekel's  Hot  Air  Sterilizer. 

Hot  air  has  but  little  penetrating  power  and  is,  therefore,  not  applicable 
to  packages  of  large  size,  for  instance,  as  rolls  of  clothing,  gauze,  etc.  The 
process  seems  particularly  adapted  to  the  sterilizing  of  surgical  glassware ; 
in  fact,  it  appears,  for  such  articles,  to  be  the  only  method  that  will  secure  an 
ideal  result  without  danger  of  breaking  the  utensils. 

As  it  is  necessary  to  determine  and  regulate  the  temperature,  ovens  and 
heating  devices  are  employed  that  will  generate  and  maintain  a  moving  cur- 
rent of  hot  air.  Air  sterilizers  are  usually  manufactured  from  sheet  iron  or 
copper,  and  consist  of  some  form  of  a  double-walled  oven  fitted  with  shelves, 
and  supplied  with,  or  placed  over,  a  suitable  heating  device.  Circulation  of 
air  is  secured  by  openings  in  the  upper  and  lower  portions.  Single-walled 
sterilizers  are  occasionally  employed.  All  should  include  a  thermometer, 
that  the  inner  temperature  may  be  noted. 

The  Plain  Hot  Air  Sterilizer,  traced  in  figure  302,  exhibits  a  hot-air 
oven  or  sterilizer  in  its  simplest  form.  It  is  manufactured  from  ordinary 


COLLIE  (£1 


152 


STERILIZATION. 


sheet  or  Russian  iron  with  single  walls.  One  shelf  serves  to  hold  the  arti- 
cles to  be  disinfected.  An  opening  is  provided  for  a  thermometer,  that  the 
temperature  may  be  regulated.  It  can  be  placed  on  a  shelf  or  table,  or  sus- 
pended from  a  wall.  The  sizes  usually  manufactured  vary  from  12  to 
24  inches  in  length. 

The  German  Pattern  of  Hot  Air  Sterilizer,  illustrated  in  figure  303, 
shows  a  double-walled  pattern  covered  with  an  external  coat  of  asbestos  to 
prevent  over-radiation  of  heat.  The  construction  of  the  two  walls  and  the 
location  of  their  openings  are  such  as  to  give  an  even,  thorough  ventilation, 
thus  securing  as  nearly  uniform  temperature  as  possible.  The  openings 
are  supplied  with  slides,  that  the  flow  of  air  may  be  properly  regulated. 
Perforated  shelves  are  provided  for  the  accommodation  of  contents.  The 
apparatiis  may  be  placed  on  a  table  or  suspended  from  a  wall.  The  sizes 
usually  manufactured  vary  in  height  from  12  to  24  inches. 

BoekePs  Hot  Air  Sterilizer,  as  outlined  in  figure  304,  is  among  the  most 
practical  of  this  class  of  apparatus.  Constructed  with  double  perforated 
walls,  perfect  ventilation  may  be  secured.  The  amount  of  air  flow  is  easily 
regulated  by  means  of  suitable  closing  slides.  Provided  with  an  improved 


Figure  305.     Beck's  Folding  Support  for  Dressings,  etc.,  and  Plain  Enamel  Ware  Boiling  Pot. 

gas  burner,  the  heat  may  be  maintained  at  any  desired  temperature ;  sup- 
plied with  a  thermometer,  the  heat  may  be  watched  and  regulated  at  will. 
By  the  aid  of  double  doors,  the  apparatus,  though  of  large  size,  may  be 
tightly  closed.  The  sizes  vary  from  1 2  to  24  inches  in  width. 


Steam  Sterilization. 

This  consists  in  bringing  the  articles  to  be  disinfected  in  d:  „  t  contact 
with  steam.  The  process  is  particularly  applicable  to  porous  oiibstances, 
such  as  dressings,  garments,  and  all  woven  or  spun  fabrics.  It  is  not  suit- 
able for  sterilizing  steel  instruments,  because  even  with  the  utmost  care, 
rusting  of  parts  or  whole  pieces  often  results. 

Solids  and  fluids  are  not  penetrated  by  steam,  being  only  directly 
affected  on  their  surfaces.  Sterilization  of  any  incorporated  micro-organ- 
isms, therefore,  must  be  by  means  of  heat  communicated  from  the  steam 
by  radiation.  9 

The  value  of  moist  heat  as  a  germicide  increases  in  proportion  to  the 
amount  of  water  it  contains.  Over-steam  (saturated)  is  of  much  greater 
value  than  under-steam  (steam  mixed  with  air).  High  pressure  steam, 
being  more  dense,  contains  more  moisture,  and  under  pressure  penetrates 
quicker,  and  owing  to  its  higher  temperature  is  more  effectual  than  satu- 


-      • 


THERMAL    STERILIZATION. 


153 


rated  (over-steam) ;  while  boiling  water,  moisture  in  its  most  condensed 
form,  furnishes  an  ideal  method  for  such  articles  as  are  not  injured  by  it. 
Steam,  owing  to  its  greater  penetrating  power,  is  a  more  valuable  germi- 
cide than  hot  air,  and  is.  therefore,  more  efficient  when  not  mixed  with  the 
latter,  its  destructive  power  being  decreased  in  proportion  to  the  amount 
of  air  incorporated  with  it.  A  sterilizer  to  be  perfect,  therefore,  should 
be  so  constructed  that  all  contained  air  may  be  expelled  and  replaced  with 
steam. 

In  an  apparatus  where  the  principles  governing  the  saturation,  conden- 
sation and  consequent  thorough  penetration  are  carefully  and  scientifically 
adjusted,  low  steam  (212°  F.)  will  destroy  spores  of  pathogenic  microbes  in 
a  few  minutes,  provided  the  steam  is  brought  in  direct  contact  with  the 
infected  substances. 

Steam  for  sterilizing  purposes  may  be  applied  according  to  four  methods: 
Low  pressure  {  Under-steam.  .  (  Saturated  steam. 

(  Over-steam.  e  {  Super-heated  steam. 

Under- Steam. 

Under  or  direct  steam  consists  of  an  upward  current  moving  from  the 
water  surface  through  or  around  the  articles  to  be  sterilized.  This  system 


Figure  306.    Jacketed  Boiling  Pot,  with 
Perforated  Bottom. 


Figure  307.    Van  Deusen's  Steam  Sterilizer. 


either  permits  the  escape  of  steam  at  the  top  of  the  sterilizer,  or  generates 
only  a  limited  quantity,  which  mixes  with  the  air  and  is  retained. 

As  air  has  a  greater  specific  gravity  than  steam,  it  is  difficult  to  force  it 
from  an  under-steam  sterilizer.  The  steam  as  fast  as  generated  ascends 
through  the  overlying  air,  mixes  with  this  air  and  collects  in  the  upper 
portion  of  the  chamber.  Air,  being  heavier,  naturally  seeks  a  lower 
level,  resulting  in  an  admixture  of  the  two,  the  proportion  varying  accord- 
ing to  the  height  above  the  water  surface :  that  is,  the  upper  portion  con- 
tains a  much  larger  percentage  of  steam,  while  the  lower  part  is  com- 
posed almost  exclusively  of  heated  air.  The  air  in  such  cases  acts  in  the 
same  manner  as  in  the  hot  air  sterilizer,  excepting  that  it  is  not  circula- 
ting, receiving  and  imparting  heat  by  radiation.  The  steam  in  instruments 
of  this  class,  moving  upward  by  force  of  gravity,  naturally  seeks  the 
channels  of  least  resistance,  thus  avoiding  the  more  densely  packed  por- 
tions of  the  chamber.  The  under-steam  system  is  fairly  exhibited  in  an 
ordinary  wash-boiler  or  boiling  pot.  In  both  of  these  household  utensils, 
the  generating  steam  ascending  from  the  surface  of  the  water  finds  an  out- 


154 


STERILIZATION. 


let  at  the  top,  or  if  partially  confined  by  a  close  fitting  cover,  mixes  with 
the  air. 

That  an  ordinary  kitchen  utensil  of  this  character  might  be  utilized  in 
the  sterilization  of  dressings,  Carl  Beck  has  devised  a  false  bottom  or  shelf 
resting  on  folding  legs,  by  means  of  which  the  articles  to  be  sterilized  may 
be  supported  above  the  surface  of  the  water,  thus  freeing  them  from  the 
danger  of  becoming  wet.  This  device  will  often  enable  a  surgeon,  partic- 
ularly if  far  away  from  a  base  of  supplies,  to  quickly  improvise  a  sterilizer 
suitable  for  disinfecting  dressings  and  even  instruments. 

Beck's  Folding  Support  for  dressings,  etc.,  as  shown  by  figure  305, 
consists  of  a  perforated  plate,  surrounded  by  a  shallow  rim  to  which  is 
attached  a  small  loop-shaped  handle,  by  means  of  which  the  appliances 
may  be  placed  in  or  removed  from  a  boiling  pot.  Three  legs,  each  about 
3  inches  in  height,  are  attached  to  the  under  surface  of  the  plate,  and  to 
facilitate  transportation  they  are  so  arranged  that  they  can  be  folded. 
This  latter  feature,  however,  we  deem  unnecessary,  because  the  circular 
plate  can  be  transported  with  the  boiling  pot  and  may  be  permitted  to 
remain  in  it,  a  part  of  the  apparatus.  When  wanted  for  use,  the  surgeon 


Figure  308.    Diagrams  Showing  Construction  of  Arnold's  Sterilizer. 

has  only  to  pour  water  into  the  pot  to  a  depth  of  about  two  inches ;  place 
the  circular  plate  in  position,  on  the  top  of  which  the  dressings  and  other 
similar  fabrics  may  be,  packed ;  cover  the  apparatus,  and  after  the  boiling 
point  is  reached,  continue  the  process  for  thirty  minutes.  If  necessary,  the 
instruments  might  be  sterilized  by  boiling  at  the  same  time,  but  as  they  do 
not  require  so  long  a  time  for  sterilization,  it  will  be  better  if  this  be  done 
in  a  separate  utensil. 

Boiling  pots  of  glazed  ware  may  be  purchased  of  the  following  diame- 
ters: 6y2,  7^  and  8^  inches. 

The  Jacketed  Boiling  Pot,  as  shown  by  figure  306,  is  of  glazed  iron  ware, 
constructed  particularly  for  steaming  purposes.  They  may  be  purchased 
of  six,  nine,  fourteen,  or  eighteen  quarts  capacity,  the  internal  measure- 
ments varying  from  8  by  10  to  12  by  12  inches.  They  furnish  an  inexpensive 
means  for  sterilizing  dressings  by  the  under-steam  system.  The  perforated 
bottom  of  the  inner  vessel  is  at  such  a  height  that  there  is  practically  no 
danger  of  the  boiling  water  saturating  the  contained  liquids.  After 
sterilization  is  complete,  the  inner  chamber  inay  be  removed  from  the  kettle 
and  conveyed  with  its  contents  to  the  operating  table. 


THERMAL    STERILIZATION. 


155 


The  Van  Deusen  or  Lee  Sterilizer,  as  shown  by  figure  307,  is  a  combina- 
tion of  an  oblong  boiling  pot,  a  false  bottom  somewhat  on  the  plan  sug- 
gested by  Beck  and  a  gable-shaped  cover.  By  means  of  the  latter,  the 
condensed  steam  collecting  under  the  roof  or  cover,  is  conducted  down- 
wards to  the  water  surface.  The  false  bottom  in  this  instrument  is  con- 
structed in  the  shape  of  a  removable  drawer  with  wire  gauze  bottom  and 
sides,  into  which  the  dressings  and  other  articles  to  be  sterilized  are  placed. 
The  lower  portion  of  the  sterilizer  is  arranged  as  an  open  boiler  into  which 
water  may  be  poured  and  there  heated  to  the  boiling  point.  The  steam 
thus  generated  ascends  from  all  portions  of  the  water  surface,  acting 
exactly  on  the  principle  before  mentioned.  Scientifically,  the  apparatus 
presents  no  features  that  are  an  improvement  upon  the  appliances  last 
described. 

The  Arnold  Steam  Sterilizer,  as  illustrated  by  figure  308,  is  at  this  time 
the  most  popular  of  the  under-steam  variety.  Its  principal  advantage 
consists  in  a  thin  double  bottom,  in  which  a  shallow  stratum  of  water  is 
brought  into  close  contact  with  the  flame,  thus  enabling  the  operator  to 


Figure  309.     Schimmelbusch's  Steam  Sterilizer. 


generate  steam  more  quickly  than  with  the  ordinary  patterns  of  boilers. 
The  steam  so  generated  passes  directly  upward  through  a  central  tube  into 
the  sterilizing  chamber,  where  it  is  partially  confined  by  means  of  a  loosely 
fitting  cover  placed  over  the  compartment.  Surrounding  the  sterilizing 
chamber  and  cover  is  a  hood,  open  at  the  bottom,  by  means  of  which  all 
water  formed  by  condensation  is  conducted  to  the  basin  below.  As  no 
means  are  provided  for  replacing  the  air  with  steam,  a  mixture  of  the  two 
results.  The  density  and  saturating  qualities  of  the  steam  vary  in  differ- 
ent portions  of  the  sterilizer,  as  the  steam  must  of  necessity  be  more  dense 
at  the  top  than  at  the  bottom.  It  is  claimed  for  the  instrument  that  the 


156 


STERILIZATION. 


heat  in  the  various  portions  of  the  sterilizing  chamber  is  the  same.  This 
may  in  some  cases  be  true,  because  the  air  in  the  lower  portion  of  the  ster- 
ilizing chamber  would  in  a  short  time  become  heated  by  radiation  to  the 
same  degree  as  the  steam  in  the  same  compartment.  The  penetrating 
and  sterilizing  qualities  of  unmixed,  saturated  steam  are,  however,  in  a 
large  degree,  lost  and  in  this  respect  the  apparatus,  so  far  as  the  steriliza- 
tion of  dressings  is  concerned,  is  inferior  to  those  furnishing  over-steam. 

Over-Steam. 

Over-steam  consists  of  a  descending  stream  in  which  the  accumulating 
steam  collecting  first  by  force  of  gravity  in  the  upper  portion  of  the  boiler, 
finds  an  outlet  at  the  bottom  where,  after  the  sterilizing  chamber  has  been 
filled  from  above  downwards,  the  surplus  of  steam  escapes  below.  This 
necessitates  the  construction  of  a  sterilizer  having  its  steam  outlet  below 
the  level  of  the  articles  to  be  sterilized.  This  method  is  particularly  appli- 
cable to  all  forms  of  dressings,  garments,  non-absorbable  ligatures,  etc., 
and  for  this  purpose  furnishes  an  ideal  application  and  ideal  results. 


Figure  310.     Boeckmann   Steam  Sterilizer, 
tional  View  Showing  Movement  of 
Steam  Currents. 


Sec- 


Figure  311.     Boeckmann   Hot  Air  Sterilizer.    Sec- 
tional View    Showing    Direction    of    Hot  Air 
Currents  when  in  Use  for  Sterilizing  Catgut. 


Over- steam  possesses  several  advantages  over  under-steam.  As  steam 
is  lighter  than  air  and  collects  in  the  upper  portion  of  the  sterilizing  cham- 
ber, it  can  make  room  for  itself  and  find  means  of  escape  only  by  forcing 
the  air  downward  and  out  of  the  sterilizer,  thus  filling  the  chamber  with 
unmixed  steam  of  sufficient  density  to  overcome  the  air  pressure.  Its 
action  in  this  case  is  similar  to  and  as  perfect  as  that  of  a  pigton.  This 
pressure  is  sufficient  to  secure  for  porous  substances  complete  penetration 
without  regard  to  the  character  or  nature  of  the  articles  in  the  sterilizer 
or  the  manner  of  packing.* 

Over-steam  not  only  secures  a  more  perfect  sterilization,  but  absorbable 
material  after  disinfection  may  be  rendered  thoroughly  dry,  provided  the 
appliance  is  so  constructed  that  hot  air  may  be  admitted  to  the  chamber 
below  the  dressings. 

To  thoroughly  test  the  action  of  the  various  currents  of  air  and  steam 
in  a  sterilizer  of  this  pattern  the  author  selected  three  glass  tubes  each 
about  T  y2  inches  in  diameter,  6  inches  long  and  closed  only  at  one  end. 
Generally  speaking  they  were  in  the  form  of  a  test  tube.  Into  each  of 


THERMAL    STERILIZ ATION.  157 

these  tubes  was  placed  250  Drains  of  hygroscopic  gauze  accurately  weighed. 
Tube  No.  i  was  placed  in  the  sterilizing  chamber  in  an  upright  position ;  i.  e., 
with  the  mouth  up;  tube  No.  2  in  a  horizontal  position  and  tube  No.  3 
overturned ;  i.  e. ,  with  the  mouth  down.  These  were  then  submitted  to 
steam  sterilization  for  thirty  minutes,  after  which  the  gauze  from  each 
tube  was  quickly  removed  and  weighed.  That  in  No.  i  weighed  252;  that 
in  No.  2,  258,  and  that  in  No.  3,  256  grains,  demonstrating  that  the  gauze 
contained  in  the  upright  tube,  owing  to  the  fact  that  the  tube  was  full  of 
air  and  that  steam  being  lighter  was  unable  to  replace  the  air,  and  that 
little  penetration  and  consequent  absorption  of  steam  by  the  gauze  took 
place.  Tube  No.  2,  which  rested  upon  its  side,  freely  admitted  steam. 
This  would  quickly  expel  the  air,  allowing  complete  penetration.  Tube 
No.  3  being  overturned  permitted  the  steam  to  enter  from  the  under  side, 
and  as  it  collected  in  the  upper  portion  of  the  overturned  tube,  forced  the 
air  out  at  the  bottom  and  secured  absorption.  It,  however,  possessed  the 
disadvantage  that  the  steam  would  not  be  moving,  and  although  the  press- 
ure would  be  the  same,  it  would  be  "dead"  steam. 

The  three  tubes  in  question,  after  weighing  and  replacing  their  con- 
tents, were  returned  to  the  sterilizer  and  each  placed  as  before,  the  cork 
in  the  top  of  the  sterilizer  withdrawn  and  the  instrument  changed  to  a  dry 
heat  apparatus.  In  fifteen  minutes  the  tubes  were  again  removed  and 
their  contents  weighed.  The  upright  and  horizontal  tubes  were  found  to 
be  absolutely  dry,  each  weighing  250  grains,  while  the  contents  of  tube 
No.  3  weighed  255  grains,  showing  that  it  was  impossible  for  the  moisture 
to  escape  owing  to  the  greater  weight  of  the  atmosphere  surrounding  the 
tube. 

We  are  indebted  to  Schimmelbusch  for  the  first  successful  application  of 
this  principle  in  surgical  sterilization. 

Schimmelbusch's  Steam  Sterilizer,  as  used  in  the  Von  Bergmann  clinic 
in  Berlin,  is  illustrated  by  figure  309.  It  consists  of  two  copper  cylinders 
of  different  sizes,  one  within  the  other,  the  space  between  them  comprising 
the  water  chamber  or  boiler,  both  being  surrounded  by  an  air  chamber  and 
an  external  covering  of  metal  and  asbestos.  A  solid  iron  cover  is  provided, 
fitting  closely  over  the  apparatus,  the  joint  being  closed  by  a  suitable  soft 
rubber  packing  adjusted  in  such  a  manner  that  by  the  aid  of  the  screw 
nuts,  shown  in  the  illustration,  it  may  be  held  firmly  in  place.  When  in 
use,  the  water  chamber  should  be  filled  about  half  full,  the  height  of  the 
fluid  being  indicated  by  a  suitable  glass  water  gauge.  Heat  is  furnished 
by  an  efficient  gas  jet  or  small  stove  placed  underneath  the  apparatus. 
Suitable  openings  are  provided  at  the  top  of  the  water  boiler  for  the 
entrance  of  the  generated  steam  into  the  inner  sterilizing  chamber.  Steam 
ascending  in  the  jacket  formed  by  the  two  cylinders,  passes  into  the  steril- 
izing chamber,  which  it  soon  fills  in  the  form  of  saturated  steam,  forcing 
the  contained  air  out  through  the  opening  at  the  bottom ;  the  surplus  steam 
finds  an  exit  through  the  same  channel.  The  escaping  steam  may,  if 
desired,  be  conducted  through  a  pipe  coiled  within  a  water  bucket  and 
there  condensed.  An  opening  in  the  cover  permits  the  introduction  of  a 
thermometer,  that  the  temperature  may  at  all  times  be  noted.  Arrange- 
ments for  filling  the  chamber  with  water  through  the  gauge  are  provided, 
a  funnel  for  this  purpose  being  introduced  at  the  top.  The  construction  of 
this  apparatus  renders  a  uniform  temperature  possible,  and  with  steam 
escaping  at  the  outlet  a  temperature  of  212°  under  open  atmospheric  press- 
ure may  be  guaranteed.  It  is  advised  in  the  use  of  this  apparatus  that  the 


158 


STERILIZATION. 


sterilization  be  continued  for  from  twenty  to  thirty  minutes,  at  the  end  of 
which  time  all  dressings  and  similar  articles  will  be  found  aseptic.  This 
appliance  is  a  perfect  working  model  of  an  over-steam  system,  a  design 
that  has  been  in  use  and  given  perfect  satisfaction  for  several  years  in 
one  of  the  most  carefully  conducted  clinics  in  the  world. 

We  are  also  indebted  to  Schimmelbusch  for  the  construction  of  a  system 
of  boxes  for  use  in  sterilizers  of  this  class,  in  which  lateral  openings  arc 
provided  for  the  admission  of  steam.  After  sterilization  these  boxes  may 
be  removed  and  closed  and  then  stored  or  conveyed  to  the  site  of  operation 
without  necessitating  the  opening  of  the  package  from  the  time  the  box  is 
filled  until  it  is  opened  at  the  time  of  operation.  These  boxes  consist  of  a 
short  metal  cylinder,  with  solid  bottom  and  a  hinged  metal  cover,  the 
latter  supplied  with  hasp  and  padlock,  that  the  contents  may  not  be  dis- 
turbed excepting  by  those  authorized  to  handle  them.  The  principal  feat- 
ure of  this  box  consists  of  one  or  two  lines  of  lateral  perforations  in  the 
sides  of  the  box  which  may  be  closed  by  sliding  metal  bands,  also  supplied 
with  perforations  that  exactly  correspond  in  size  and  location  with  those  in 
the  box.  These  bands  are  arranged  with  a  stop,  so  that  by  sliding  the 
band  to  one  side  or  the  other,  the  openings  in  the  two  parts  may  match  or 


Figure  312.    Boeckmann  Sterilizer,  Showing  Box  for  the  Dry  Heat  Sterilization  of  Catgut. 

mismatch,  as  desired.  When  matched,  steam  is  freely  admitted  to  the 
interior  of  the  box;  when  mismatched,  all  openings  are  closed,  in  which 
condition  the  package  is  fairly  well  protected  and  its  contents,  if  undis- 
turbed, may  be  kept  in  an  aseptic  condition  for  a  considerable  length  of 
time. 

For  transportation,  leather  covers  may  be  provided  for  these  boxes  that 
there  may  be  no  danger  of  infection  while  en  route.  The  external  diameter 
of  these  boxes  should  be  slightly  less  than  the  internal  diameter  of  the 
sterilizing  chamber,  and  their  height  so  adjusted  that  two  of  them  will  fill 
the  chamber  to  the  top. 

It  is  customary,  however,  in  the  Von  Bergmann  clinic  to  use  only  one 
of  these  boxes,  the  balance  of  the  space  being  filled  by  an  open  metal 
bucket,  in  which  larger  and  heavier  articles,  such  as  robes,  towels,  etc.,  are 
sterilized,  the  use  of  the  closed  box  being  confined  to  the  sterilization  of 
dressings,  etc.  This  sterilizing  apparatus  is  of  firm  construction  and  in 


THERMAL    STERILIZATION.  159 

three  sizes.     They  are  usually  manufactured  from  copper  with  solid  iron 
covers,  and  brass,  nickel-plated  sterilizing  boxes. 

Boeckmann's  Steam  Sterilizer,  as  portrayed  in  figure  310,  exhibits  an 
over-steam  sterilizer  efficient  in  service,  yet  of  much  lighter  construction, 
than  the  pattern  of  Schimmelbusch.  In  its  construction  two  cylinders  are 
employed,  each  one  of  which  is  open  at  one  end  and  terminates  at  the 
other  end  in  a  funnel  with  a  small  opening  at  the  apex. 

These  cylinders  are  of  different  sizes,  the  smaller  one  being  about  one 
inch  less  in  diameter  than  the  larger.  In  the  construction  of  the  sterilizer, 
the  smaller  of  the  two  cylinders  is  inverted,  as  shown  in  the  illustration,  the 
larger  or  outer  one  serving  as  a  hood  or  cover,  the  space  between  the  two 
walls  forming  a  jacket,  thus  permitting  the  free  passage  of  steam  from 
below  upward.  The  smaller  or  inverted  cylinder  is  framed  in  the  center 
of  a  circular  boiler,  the  adjustment  of  which  is  such  that  steam  generated 
in  the  boiler  passes  upward  between  the  two  cylinders  without  coming  in 
contact  with  the  inner  or  sterilizing  chamber. 

We  have  endeavored  to  make  this  special  feature  appear  clear  to  the 
reader,  because  it  is  in  this  respect  that  this  apparatus  differs  from  under- 
steam  sterilizers.  By  referring  to  the  illustration,  the  parts  may  be  readily 
recognized:  A,  showing  the  upper  margin  of  the  water  boiler;  B,  the 
external  hood  or  larger  cylinder ;  C,  the  smaller  and  internal  or  sterilizing 
chamber.  The  space  occupied  by  the  water  is  shown  by  W,  and  the 
arrows  leading  from  the  water  surface  indicate  the  direction  taken  by  the 
generated  steam.  A  flame  plate  is  located  underneath  the  instrument,  so 
constructed  as  to  receive  the  direct  flame  cf  the  heating  apparatus.  In 
this  illustration  the  small  opening  at  the  top  is  closed  with  a  cork,  to  pre- 
vent the  escape  of  steam  at  this  point.  The  steam  as  fast  as  generated 
passes  to  the  upper  portion  of  the  sterilizer,  where  it  accumulates  in  accord- 
ance with  the  law  of  specific  gravity  and  consequent  air  pressure.  As  the 
steam  increases  in  quantity,  density  and  pressure,  it  naturally  seeks  the 
only  available  outlet,  and  working  its  way  downward  soon  expels  all  the 
contained  air  in  the  chamber  and  finds  egress  at  the  bottom  of  the  sterilizer, 
immediately  over  the  flame  plate  above  referred  to. 

The  freeing  of  the  chamber  from  air  is  thus  accomplished  automatically, 
the  result  being  the  filling  of  the  chamber  with  saturated  low  pressure 
over-steam,  a  germicide  second  only  in  value  to  boiling  water.  As  it  is 
held  in  place  by  air  pressure,  its  penetrating  powers  when  applied  to 
porous  materials  are  sufficient  to  completely  permeate  every  fiber  and  pore, 
securing  an  even  temperature  and  a  uniform  result  in  every  portion  of  the 
sterilizing  chamber.  In  the  downward  passage  of  the  steam  it  does  not,  as 
in  under-steam,  seek  the  channels  of  least  resistance,  but  like  saturation  in 
water,  every  nook  and  corner  of  the  chamber  is  filled  with  the  stream  of 
moving  steam. 

Converted  into  a  Hot  Air  Sterilizer. 

The  changing  of  this  instrument  from  a  steam  to  a  hot  air  sterilizer  is 
simple,  and  consists  only  in  removing  the  cork  before  referred  to.  This 
permits  the  escape  of  all  contained  steam  at  the  top  of  the  instrument  and 
steam  can  not  be  forced  through  the  sterilizing  chamber  or  brought  into 
contact  with  its  contents.  As  a  result,  a  current  of  hot  air  is  at  once  estab- 
lished. This  air  acting  upon  the  principle  of  an  ordinary  hot  air  furnace, 
rushes  into  the  sterilizer  at  the  bottom  where  openings  over  the  flame  plate 
are  provided,  and  passing  upward  through  the  sterilizing  chamber  imme- 
diately converts  the  instrument  into  a  drying,  instead  of  a  dampening 


160 


STERILIZATION. 


apparatus.  This  is  a  great  advantage,  because  after  the  completion  of  the 
steam  sterilizing  process  all  articles  in  the  chamber  may  be  dried  by  means 
of  a  hot  air  current  simply  by  removing  the  cork,  thus  enabling  the  oper- 
ator to  remove  from  the  sterilizer  absolutely  dry  steam  sterilized  products; 
an  advantage  which  we  believe  is  not  possessed  by  any  other  instrument. 
The  benefits  of  an  apparatus  by  means  of  which  steam  sterilized  products 
may  be  thoroughly  dried  can  not  be  underestimated.  Moist  dressings 
form  excellent  media  for  the  propagation  of  micro-organisms.  The  con- 


Figure  313.    High  Pressure  Steam  Sterilizer. 


version  into  a  hot  air  sterilizer  also  admits  of  the  employment  of  this  instru- 
ment as  a  sterilizer  for  catgut  and  other  articles  that  require  dry  heat 
sterilization. 

High  Pressure  Steam. 

High  pressure  steam  is  evolved  in  a  closed  chamber,  the  amount  of 
pressure  depending  on  the  quantity  of  steam  generated  and  the  space  it 
occupies.  The  use  of  this  system  is  usually  confined  to  hospitals  where 
sterilization  on  an  extensive  scale  is  necessary,  the  steam  being  conveyed 
directly  from  the  engine  room  boiler  or  generated  in  special  boilers  con- 
structed for  the  purpose.  High  pressure  steam  is  the  most  powerful  germ 
annihilator  excepting  boiling  water,  and  at  231°  F.  at  5  Ibs.  or  more  press- 
ure, will  kill  all  forms  of  surgical  bacteria  and  their  spores  in  five  minutes. 
It  may  be  safely  stated  that  at  this  pressure,  steam  is  bacteriologically  and 
surgically  perfect.  This  system  requires  no  other  apparatus  than  the  gen- 
erator and  a  suitable  steam  chamber  provided  with  a  door  of  sufficient  size 
to  permit  the  introduction  and  removal  of  the  articles  to  be  sterilized. 

High  pressure  steam  is  in  extensive  use  by  French  surgeons  for  the 
sterilization  of  both  dressings  and  instruments.  The  apparatus  employed 
by  them  for  this  purpose  is  called  an  autoclave,  and  consists  of  a  jacketed 
boiler  provided  with  inlet  and  outlet  pipes,  so  adjusted  that  steam  under 


THERMAL    STERILIZATION.  161 

any  desired  pressure  may  be  admitted  to  the  sterilizing  chamber.  Entrance 
to  this  chamber  is  effected  by  means  of  a  cover  or  door  securely  held  in 
place  by  strong  clamps  and  provided  with  a  registering  gauge  and  steam 
valve. 

The  High  Pressure  Steam  Sterilizer,  pictured  in  figure  3 1 3,  exhibits  an 
apparatus  designed  for  the  rapid  sterilization  of  surgical  dressings  by  press- 
ure steam.  It  consists  of  a  copper  cylinder  of  steam  boiler  construction, 
one  end  closed  with  a  head  firmly  riveted  in  place,  the  other  provided 
with  a  suitable  swinging  door.  This  door  is  secured  by  numerous  project- 
ing arms  or  bolts.  These  bolts  are  controlled  by  a  lever  and  wheel,  both 
so  arranged  that  the  bolts  may  be  thrown  outward  or  inward  as  required. 
A  safety  valve  and  pressure  gauge  are  provided,  the  former  usually  register- 
ing a  pressure  of  30  pounds  to  the  square  inch.  Steam  may  be  procured 
direct  from  a  boiler  system,  in  which  case  a  controlling  valve  should  be 
placed  between  the  boiler  and  the  sterilizer,  that  the  pressure  in  the  latter 
may  be  kept  within  proper  limits.  Many  are  constructed  with  the  steam 
boiler  located  in  the  bottom  of  the  sterilizing  chamber,  so  arranged  that 
steam  may  be  quickly  generated  by  means  of  a  suitable  gas  burner  which 
extends  the  full  length  of  the  boiler.  If  properly  constructed,  steam  may 
be  generated  by  this  method  in  from  five  to  ten  minutes.  This  apparatus 
furnishes  an  efficient  method  of  steam  sterilization.  Usually  the  boiler  is 
surrounded  by  a  neat  polished  or  nickel-plated  copper  jacket.  The  usual 
size  is  about  fourteen  inches  in  internal  diameter  and  twenty-two  inches  in 
length.  A  larger  sterilizer,  twenty  by  twenty-eight  inches,  is  employed  in 
some  of  the  larger  hospitals.  Where  desired,  wire  gauze  baskets  may  be 
provided  by  means  of  which  dressings  may  be  introduced  into  and  removed 
from  the  sterilizing  chamber.  A  stop-cock  is  provided  so  that  the  steam 
contents  may  be  withdrawn  from  the  chamber  after  sterilization.  The 
natural  warmth  of  the  boiler  will  then  expel  any  moisture  in  the  contained 
dressing  in  from  five  to  ten  minutes. 

In  buildings  heated  by  steam  or  where  the  operating-room  can  be  con- 
nected with  a  steam  boiler,  live  steam  may  be  connected  with  and  admitted 
directly  into  the  sterilizer.  This  plan  furnishes  a  practical  and  efficient 
means  and  secures  perfect  results. 

Appliances  of  this  character  may  be  used  for  all  fabrics  employed  in 
operation,  including  silk  ligatures,  dressings,  operators',  nurses',  patients' 
and  visitors'  gowns,  sheets,  towels,  etc. 

Superheated.  Steam. 

Superheated  steam  is  saturated  steam  heated  to  a  high  degree  by  being 
passed  through  heated  pipes  or  coils.  These  pipes  or  coils  are  usually 
brought  into  direct  contact  with  the  flame  surface.  Steam  thus  heated 
expands  rapidly,  and  separates  into  various  gases.  For  this  reason  and 
as  it  does  not  possess  the  penetrating  qualities  of  saturated  steam,  it 
is  not  much  superior  to  superheated  air.  It  may  be  utilized  in  the  same 
manner  as  ordinary  high  pressure  steam,  but  we  believe  it  is  seldom 
employed  for  purposes  of  disinfection. 

Boiling  Sterilization. 

Boiling  water  is  practically  our  most  powerful  germicide,  the  rapidity 

of  its  action  being  excelled  only  by  flame  contact.      It  is,  however,  more 

certain  than  the  latter,  because  every  part  of  the  article  to  be  sterilized 

may  be  brought  into  direct  and  simultaneous  contact  with  an  intense  and 

11 


162 


STERILIZATION. 


uniform  degree  of  heat.  As  this  method  will  destroy  with  certainty  all 
forms  of  pathogenic  micro-organisms  and  their  spores  within  five  minutes, 
it  forms  an  ideal  process.  As  water  can  be  quickly  heated  to  the  boiling 
point,  it  is  a  time  saver.  As  the  boiling  mass  possesses  a  nearly  uniform 
temperature  throughout,  the  system  can  be  depended  upon  for  thorough 
work.  As  it  requires  no  extensive  appliances,  chemicals  or  waste  of  time, 
it  is  economical. 

One  of  the  most  essential  elements  in  the  conduct  of  an  operation  is 
sterilized  water,  both  hot  and  cold.  As  water  is  easily  contaminated  and 
affords  a  favorable  medium  for  the  culture  of  micro-organisms,  it  should 
either  be  sterilized  fresh  for  each  operation  or  appliances  provided  in 
order  that  it  may  be  maintained  aseptic  for  an  indefinite  period. 


Figure  314.    Hot  and  Cold  Water  Sterilizer. 


Figure  315.    Plain  Water  Sterilizer. 


The  Hot  and  Cold  Water  Sterilizer,  outlined  in  figure  314,  is  constructed 
for  supplying  hot  and  cold  sterilized  water  for  office  or  hospital  use.  The 
apparatus  is  simple  in  construction  and  automatic  in  its  arrangement.  It 
may  be  attached  to  any  street  or  tank  water  system  by  means  of  the  lower 
connecting  pipe  shown  in  the  center  of  the  illustration. 

A  cylindrical  filter  of  special  design  is  provided,  through  which  the 
water  passes  on  its  way  to  the  boiler.  This  filter  is  in  two  sections, 
clamped  together  with  four  bolts  in  such  a  manner  that  the  apparatus  may 
be  easily  separated  whenever  'it  is  necessary  to  cleanse  the  filter.  Two 
methods  of  heating  are  provided,  one  by  means  of  coiled  steam  pipes  con- 
necting directly  with  a  boiler  system,  the  other  consisting  of  gas  heaters, 
gasoline  or  oil  stoves.  One  boiler  is  used  for  heating  purposes,  a  pressure 


THERMAL    STERILIZATION. 


1C3 


gauge  registering  the  amount  of  steam  pressure  if  any.  A  safety  valve  is 
also  provided  by  means  of  which  over-pressure  is  avoided.  During  the 
boiling  process  connection  between  the  tanks  should  be  closed.  After  boil- 
ing, by  opening  the  cocks  connecting  the  two  tanks,  the  steam  pressure 
may  be  utilized  by  a  special  siphon  to  force  the  water  from  the  heating 
into  the  cooling  tank,  after  which  the  first  tank  may  be  again  filled  and 
heated  as  before.  The  cooling  tank  is  provided  with  a  coil  that  may  be 
connected  direct  with  a  street  system  and  employed  for  cooling  purposes. 
Arrangements  are  provided  by  means  of  which  all  air  entering  the  tanks 
may  be  filtered  through  cotton,  thus  preventing  the  admission  of  micro- 
organisms. Water  gauges  indicate  the  amount  of  water  in  either  tank. 

The  Plain  Hot  and  Cold  Water  Sterilizer,  exhibited  by  figure  315,  consists 
of  two  tanks  arranged  on  a  single  stand,  one  adjusted  so  that  it  may  be  heated 
by  a  gas  or  gasoline  stove,  the  other  for  storage  of  cold  sterilized  water. 
These  two  tanks  are  placed  one  above  the  other,  that  the  lower  one  may  be 
filled  from  the  upper  by  the  force  of  gravity.  The  smaller  tank  in  which 
the  water  is  heated  is  of  lo-gallon  capacity.  This  tank  is  connected  directly 
with  a  water  system  or  supply  tank  by  a  suitable  pipe.  All  water  entering 
this  tank  passes  through  a  natural  stone  filter,  having  a  capacity  of  150 


Figure  316.    Plain  Instrument  Boiler. 


Figure  317.    Kean's  Instrument  Sterilizer. 


gallons  per  hour  under  an  ordinary  city  pressure.  This  tank  is  supplied 
with  a  water  gauge  by  which  over-filling  may  be  avoided.  It  is  connected 
directly  with  the  cold  water  storage  tank,  a  stop-cock  permitting  or  stopping 
the  flow.  The  lower  tank  is  also  provided  with  a  water  gauge.  Both  are 
supplied  with  cocks  by  which  the  contents  may  be  withdrawn.  The  whole 
stand,  including  the  filter  support,  is  80  inches  in  height,  and  occupies  a 
floor  space  about  20  inches  square. 

Boiling  water  is  particularly  applicable  to  the  sterilization  of  instruments, 
because  certain  in  its  action,  and  when  properly  conducted  non-injurious. 

A  Boiling  Water  Instrument  Sterilizer  is  almost  a  necessity  during  opera- 
tions. It  may  be  placed  upon  the  dressing  table,  or  upon  a  special  stand 
provided  for  this  purpose.  As  an  infected  instrument  may  be  perfectly 
sterilized  in  from  one  to  two  minutes  by  immersion  in  boiling  water,  it  fol- 
lows that  if  an  abscess  is  opened,  if  an  instrument  is  dropped  upon  the 
floor,  or  in  any  way  brought  into  contact  with  infected  matter,  it  may  be 
rendered  aseptic  by  being  thus  immersed  in  boiling  water. 

It  will  be  of  great  advantage  in  the  use  of  instrument  sterilizers  if  each 
be  provided  with  some  form  of  metal  rack  or  basket,  by  means  of  which  the 
instruments  may  easily  be  immersed,  and  as  readily  removed  from  the 
boiling  water.  Such  a  rack  or  basket  may  be  made  of  woven  wire,  or  of 


164  STERILIZATION. 

perforated  metal,  the  former  being  preferred.  In  an  apparatus  con- 
structed with  such  an  appliance,  the  instruments  may  be  carefully  placed 
in  the  bottom  of  the  basket,  the  basket  immersed  in  the  boiling  water  and 
thence,  after  sterilization,  removed  and  immersed  in  a  suitable  tray  filled 
with  sufficient  antiseptic  solution  to  cover  them. 

The  Plain  Instrument  Boiler,  as  shown  in  figure  316,  is  made  with 
rounded  ends  and  supplied  with  a  suitable  cover  and  rack.  Usually  they  are 
of  granite  or  other  glazed  ware  and  may  be  heated  on  a  stove,  gas  or  gaso- 
line range.  Two  or  a  row  of  three  Bunsen  burners  furnish  a  quick 
method  of  heating  sterilizers  of  this  variety.  The  regular  size  is  4^  inches 
deep,  6^2  inches  wide  and  16  inches  long.  Surgical  instruments  may  be 
perfectly  sterilized  in  them,  and  while  they  do  not  present  an  attractive 
appearance,  they  are  preferred  by  many  operators  on  account  of  their 
low  price. 

Kean's  Instrument  Sterilizer,  as  illustrated  in  figure  317,  consists  of  a 
plain  oblong  boiler  with  a  cover,  and  contains  a  wire  gauze  basket  in 
which  the  instruments  may  be  placed.  Folding  legs  are  provided  that  the 
apparatus  may  be  raised  above  the  table  or  shelf  upon  which  it  rests,  thus 
allowing  space  beneath  for  the  arrangement  of  an  alcohol  lamp  which 
forms  part  of  the  apparatus.  It  may,  however,  be  heated  by  a  stove. 
They  are  generally  composed  of  copper  nickel-plated.  The  sizes  usually 
manufactured  vary  from  10  to  16  inches  in  length. 


Boeckmann's  Instrument  Sterilizer. 


Boeckmann's  Instrument  Sterilizer,  as  set  forth  in  figure  318,  illustrates 
an  appliance  embodying  plans  similar  to  those  exhibited  in  the  steam 
sterilizer  devised  by  the  same  author  and  shown  in  figure  310.  The 
apparatus  consists  of  a  copper  boiler  15  inches  long,  8  inches  wide 
and  4  inches  deep,  in  the  center  of  which  is  an  upright  metal  tube 
attached  to  the  bottom  of  the  boiler,  the  lumen  of  which  continues  through 
the  latter  where  it  finds  an  outlet  over  the  flame  plate.  The  removable 
pan-shaped  cover  which  fits  closely  to  the  inner  walls  of  the  boiler  is 
reversed  over  the  surface  of  the  water  in  such  a  manner  that  the  steam 
generated  in  the  apparatus  is  retained  until  sufficient  to  fill  the  sterilizer 
with  over-steam,  the  surplus  escaping  through  the  tube  before  mentioned. 
This  cover  not  only  assists  in  retaining  the  heat  but  in  securing  a  uniform 
temperature  in  all  parts  of  the  boiler.  To  facilitate  the  introduction  and 
removal  of  instruments  without  disturbing  them,  a  wire  basket  with  suit- 
able handles  is  provided  in  which. the  instruments  may  be  arranged  before 
their  introduction  into  the  boiling  water.  This  apparatus  may  be  heated 
over  an  ordinary  kitchen  or  gas  stove,  or  a  gasoline  or  gas  burner.  Suit- 
able handles  are  provided  for  lifting  the  entire  sterilizer,  for  lifting  the 
cover  separately  and  for  removing  all  the  instruments  at  once. 

A  portable  sterilizer  in  which  both  instruments  and  dressings  might  be 
simultaneously  sterilized,  each  by  the  most  approved  plan,  has  long  been 


THERMAL    STERILIZATION. 


165 


sought,  and  much  time  and  money  has  been  spent  in  attempting  to  secure 
a  practical  pattern.  Among  the  many  models  that  have  been  suggested, 
the  following  are  worthy  of  special  notice: 

Lord's  Steam  Sterilizer,  as  traced  in  figures  319  and  320,  combines  the 
advantages  of  steam  and  dry  heat  sterilization  and  has  in  addition  an 
independent  heating  apparatus,  the  whole  being  included  in  one  appliance. 

It  is  supplied  with  gauze  basket  for  dressings,  etc.,  a  tray  in  which 
instruments  may  be  boiled,  an  alcohol  stove,  a  folding  stand  upon  which 
the  apparatus  may  be  placed,  and  a  thermometer  by  means  of  which  the 
temperature  may  be  noted.' 

Figure  319  exhibits  the  apparatus  closed  for  transportation.  The  han- 
dle standards  A  and  B  are  both  hollow7.  One  is  supplied  with  an  outlet  by 
means  of  which  any  surplusage  of  steam  may  be  permitted  to  escape.  "A" 
is  provided  with  a  perforated  cork  through  which  a  thermometer  may  be 
passed  into  the  interior  of  the  sterilizing  chamber.  The  gauze  basket  may 
be  utilized  for  removing  the  dressings  after  sterilization.  The  instrument 
tray  may  not  only  be  employed  for  boiling  the  instruments,  but  as  a  tray 
for  use  during  operations.  The  sterilizer  may  be  heated  by  means  of 
an  alcohol  stove,  or  upon  an  ordinary  range  or  over  a  suitable  lamp.  By 
means  of  a  slide  arranged  immediately  over  the  flame  plate,  the  water 
boiler  may  be  removed  and  the  sterilized  contents  thoroughly  dried  by 


Figure  319.    Lord's  Portable  Combined  Steam  Sterilizer. 


means  of  heat  direct  from  the  lamp  or  burner.  This  is  an  advantage  not 
possessed  by  many  instruments  of  this  class.  The  whole  forms  a  compact 
apparatus,  well  suited  for  transportation.  Dressings,  gowns,  aprons,  etc., 
may  be  carried  in  the  gauze  basket.  They  are  manufactured  in  two  sizes, 
one  i6l/2  inches  long  for  general  use,  the  other  smaller,  12^  inches  in  length, 
intended  for  the  use  of  oculists,  aurists,  etc. 

Boeckmann's  Combined  Sterilizer,  as  shown  in  figure  321,  illustrates  a 
pattern  which,  in  brief,  consists  in  placing  a  steam  sterilizing  chamber  over 
the  instrument  sterilizer  described  on  page  164.  The  latter  is  constructed 
on  exactly  the  same  plan  as  the  plain  instrument  sterilizer,  excepting  that 
in  place  of  the  cover,  it  is  supplied  with  a  hood  that  entirely  envelops  the 
sterilizing  chamber.  This  hood  rests  in  a  groove  placed  flush  with  the  top 
of  the  instrument  sterilizer,  so  adjusted  that  it  may  be  filled  with  water, 
forming  a  steam-tight  joint,  any  surplus  water  from  which  will  run  back 
into  the  boiler. 

By  boiling  water  in  the  instrument  sterilizer  the  steam  produced  passes 


166 


STERILIZATION. 


upward  and,  meeting  with  the  under  wall  of  the  sterilizing  chamber,  is 
diverted  outward  where  it  passes  upward  through  the  jacket  formed 
between  the  latter  and  the  cover,  reaches  the  top  of  the  instrument  where 
it  accumulates  underneath  the  hood.  This  steam  soon  replaces  the  air, 
and  then  passes  into  the  sterilizing  chamber,  forcing  the  air  out  through 
the  opening  at  the  bottom.  The  instrument  further  possesses  the  advan- 
tage" of  efficient  dry  heat  sterilization.  When  required  for  use,  the  instru- 
ment tray  should  be  removed  from  the  sterilizer,  the  chamber  packed  with 


Figure  320.    Lord  Sterilizer,  Showing  Separate  Instrument  Sterilizer  and  Alcohol  Lamp  with  Stand. 


the  dressings  to  be  disinfected,  the  cover  of  the  latter  and  the  hood  placed 
in  position  and  heat  applied.  After  the  generation  of  steam  and  its  con- 
tinuance for  twenty  minutes,  the  hood  and  chamber  may  be  temporarily 
removed,  the  instrument  basket,  together  with  the  instruments,  immersed 
in  the  boiling  water,  the  chamber  and  hood  replaced,  the  cork  removed 
from  the  latter  and  the  heat  continued  for  five  minutes.  This  will  be 
found  sufficient  not  only  to  sterilize  the  instruments  by  boiling,  but  to 
thoroughly  dry  the  contents  of  the  sterilizing  chamber. 

Figure  321  also  exhibits  the  sterilizer  with  the  hood  removed.  It  shows 
the  sterilizing  chamber  in  which  may  be  placed  the  dressings,  robes,  liga- 
tures, etc.  No  particular  system  of  packing  is  required  because  the 


Figure  321.    Boeckmann's  Combined  Instrument  and  Dressing  Sterilizer. 

method  secured  by  this  device  insures  perfect  penetration  in  all  parts  of 
the  sterilizing  chamber. 

Figure  322  illustrates  the  instrument  tray  in  which  the  instruments  may 
be  placed  ready  for  immersion  at  the  proper  time  and  removed  from  the 
sterilizer.  An  adjoining  illustration  also  shows  the  instrument  sterilizer 
with  tray  and  instruments  in  place,  over  which  the  sterilizing  chamber  and 
hood  are  to  be  placed. 

Dudley's  Instrument  Case  and  Sterilizer,  as  shown  by  figure  323,  consists 
of  two  metallic  boxes,  both  of  the  same  size  and  with  folding  legs,  ar- 
ranged not  only  as  cases  for  the  transportation  of  surgical  instruments. 


THERMAL    STERILIZATION. 


167 


dress-'ngs,  etc.,  but  for  use  as  sterilizers  at  the  time  of  operation.  Each 
box  is  supplied  with  trays,  basins,  alcohol  stove,  etc.,  and  the  whole  forms 
a  complete  and  adequate  equipment.  Practically  the  apparatus  consists  of 
two  rectangular  sterilizers  adapted  for  use  of  both  boiling  and  under-steam 
sterilization.  Each  is  supplied  with  wire  trays  in  which  to  place  towels, 
dressings,  ligatures,  instruments,  etc.  Detachable  handles  are  provided 
with  which  these  trays  may  be  manipulated.  Basins  are  provided  for 
sponges,  ligatures,  etc.  The  alcohol  stoves  are  supplied  with  regulators, 
so  that  any  desired  degree  of  heat  may  be  obtained. 


Figure  322.     Boeckmann  Combination  Sterilizer,  Showing  Arrangement  for  Boiling  Instruments. 


Figure  324  exhibits  the  sterilizer  when  in  use  as  dressing,  instrument, 
sponge  and  ligature  trays  during  the  progress  of  an  operation.  By  this 
method  of  arrangement  all  desired  articles  are  within  easy  reach  of  the 
operator,  the  whole  being  systematically  arranged. 

As  shown  by  figure  325,  the  outfit  may  be  closely  packed  for  trans- 
portation. Both  sterilizers  being  filled,  one  is  placed  above  the  other,  the 
two  being  placed  in  a  canvas  bag  supplied  with  straps  and  handles  for 
carrying.  When  filled  with  an  ordinary  supply  of  dressings,  instruments, 
etc.,  the  apparatus  weighs  about  25  pounds. 


Figure  323.    Dudley's  Instrument  Cases  When  Used  as  Sterilizers. 

Sprague's  Instrument  Sterilizer  differs  from  those  previously  described 
in  that  it  is  not  portable.  It  is  more  in  the  form  of  a  fixture  and  may  com- 
prise a  part  of  the  permanent  operating-room  equipment.  It  is  rectangular 
in  form,  15  inches  in  length,  8  inches  in  width,  and  6  inches  in  depth.  While 
it  may  be  of  copper,  sheet  bronze  heavily  tinned  and  nickel-plated  on  the 
inside  furnishes  the  best  material.  Outside  they  are  usually  bronzed, 
highly  polished  or  nickel-plated.  Figure  326  exhibits  a  special  gas  burner 
by  means  of  which  water  may  be  boiled  in  from  three  to  five  minutes. 


168 


STERILIZATION. 


APPLICATION  OF  STERILIZATION. 


Having  previously  described  the  various  systems  that  may  be  practically 
utilized  in  sterilization,  it  is,  we  believe,  proper  to  show  the  application 
of  these  systems  to  the  various  articles  requiring  disinfection. 

The  operating-room,  together  with  its  furniture,  may  be  kept  clean  by 
means  of  hot  soda  solutions.  Mechanical  and  chemical  sterilization  of  the 
hands  and  arms  of  the  operator  and  his  assistants,  together  with  the  field 
of  operation,  have  been  so  fully  described  elsewhere  as  to  require  no  fur- 
ther mention  here.  While  glassware  may  be  successfully  sterilized  by 
mechanical  and  chemical  methods,  the  most  satisfactory  process  is  to  treat  it 
by  dry  heat.  This  method  is  to  be  preferred,  because  it  is  more  reliable 
and  there  is  less  danger  of  breakage.  The  latter  is  an  important  feature, 
because  when  an  article  is  broken,  it  is  usually  the  result  of  an  accident 


Figure  324.    Dudley's  Sterilizer,  Arranged  on  an  Instrument  Table  During  an  Operation. 

during-  cleansing,  and  as  the  ware  is  quite  expensive,  that  process  should 
be  adopted  which  reduces  the  risk  of  breakage  to  the  minimum. 

Surgical  instruments  can  be  successfully  sterilized  only  in  boiling  water 
or  boiling  alkaline  solutions,  all  other  processes  heretofore  employed  hav- 
ing proved  inefficient. 

According  to  Schimmelbusch,  it  has  not  only  been  demonstrated  that  a 
one  or  two  per  cent,  solution  of  soda  fully  protects  instruments  from  rust- 
ing, but  that  the  addition  of  soda  gives  greater  effect  to  the  germ  destroy- 
ing power  of  the  boiling  water,  on  account  of  the  solvent  and  permeating 
action  of  the  alkali.  He  further  asserts  that  "the  boiling  soda  solution  is 
the  most  powerful  germicidal  agent  known  to  us  which  is  applicable  in 
practice." 

In  order  that  a  sufficient  quantity  of  soda  may  be  incorporated  in  making 
these  solutions,  it  is  advisable  to  keep  on  hand  either  small  vials  or  pack- 


APPLICATION    OF    STERILIZATION. 


169 


ages  of  known  weight,  or  a  saturated  solution,  which  will  enable  the  assist- 
ant to  prepare  a  mixture  of  proper  strength. 

Before  attempting  to  sterilize  surgical  instruments  by  thermal  meas- 
ures, they  should  be  thoroughly  cleansed  by  mechanical  means,  supple- 
mented by  the  use  of  such  germicides  as  may  be  deemed  proper.  Instru- 
ments should  not  be  immersed  in  hot  water  for  sterilization  until  they  have 
been  thoroughly  cleaned  by  brush  and  soap,  particularly  after  an  operation. 

In  the  sterilization  of  surgical  instruments  it  will  be  well  for  the  reader 
to  remember  that  leather  articles  and  many  that  are  composed  partly  of 
rubber,  will  not  admit  of  either  steam  or  hot  air  sterilization.  This  is  par- 
ticularly true  of  leather,  and  before  boiling  appliances  constructed  with 
even  a  small  piece  of  leather,  the  latter  must  be  removed,  or  otherwise  it 
will  become  so  shrunken  and  damaged  as  to  be  unfit  for  use.  This  applies 
particularly  to  syringes  with  leather  packing,  to  respirators,  inhalers,  and 
other  articles  which  may  contain  leather. 


Figure  325.    Dudley's  Instrument  Case  and  Sterilizer  Packed  for  Transportation. 

Many  forms  of  instruments,  such  as  mirrors,  electric  lamps,  etc., 
can  be  sterilized  by  mechanical  or  chemical  measures  only. 

Care  should  be  exercised  that  instruments  are  not  injured  by  rough 
handling.  Those  with  cutting  edges  should  be  carefully  protected,  while 
small  and  delicate  instruments  must  be  guarded  from  contact  with  larger 
and  heavier  ones,  otherwise  they  may  become  injured  either  in  placing  in 
or  removal  from  the  instrument  boiler.  Forceps,  scissors,  and  instruments 
of  this  character  may  be  placed  in  small  linen  bags,  each  provided  with  a 
draw  string,  that  they  may  be  closed  and  the  instruments  thus  prevented 
from  dropping  out  of  the  package.  The  strings,  if  left  with  ends  of  suffi- 
cient length,  will  be  found  useful  in  removing  the  bags  from  the  boiling 
water.  The  edges  of  knives  must  be  protected  either  by  loosely  wrapping 
the  blades  in  cotton,  or  by  placing  them  in  suitable  racks,  such,  for 
instance,  as  is  illustrated  by  figure  327. 

Racks  of  this  character  may  be  provided  for  any  number  of  knives 
that  may  be  required  for  any  given  operation.  The  rack,  by  the  aid 
of  a  suitable  forceps,  may  be  placed  in  the  sterilizer,  from  which  it  may  be 
taken  and  immersed  in  an  instrument  tray.  From  this  the  surgeon  may 
select  his  knives  from  time  to  time,  knowing  that  they  are  not  only  aseptic, 
but  that  their  edges  have  not  been  brought  into  contact  with  anything 
that  will  dull  or  injure  them. 


170 


STERILIZATION. 


These  racks  may  be  protected  for  transportation  by  being  packed  in  a 
metallic  box  provided  with  a  hinged  or  a  plain  slip-over  cover.  Metal 
boxes  constructed  on  the  latter  plan  can  be  manufactured  from  light 
material,  and  if  sterilized  with  the  instruments,  will  form  a  safe  receptacle 
for  this  purpose. 

Too  much  care  can  not  be  exercised  in  the  cleansing  and  sterilizing  of 
surgical  instruments  following  operation.  As  soon  as  possible  thereafter, 
they  should  be  thoroughly  washed  in  tepid  water  in  which  all  blood,  fat, 
and  masses  of  tissue  should  be,  so  far  as  possible,  removed.  They  should 
next  be  immersed  and  scrubbed  with  soap  or  brushed  in  a  hot  soda  solu- 
tion. From  this  they  should  be  taken  and  after  careful  wiping  they  should 
be  immersed  in  the  instrument  sterilizer  and  boiled  for  five  minutes,  after 
which  they  should  be  wiped  dry,  and  polished  with  a  soft  sterile  linen 


Figure  326.    Sprague's  Instrument  Sterilizer. 

cloth.  They  may  then  be  permanently  stored,  either  in  the  instrument 
case  or  in  clean,  dry,  aseptible  rolls  prepared  for  the  purpose.  In  the 
wiping  and  polishing  of  cutting  instruments,  care  should  be  taken  that 
the  blades  are  not  dulled,  and  to  avoid  this  the  assistant  should  be  trained 
not  only  to  see  that  the  edges  are  always  protected,  but  that  in  wiping  the 
blades  the  direction  of  the  force  employed  is  directed  over  and  away  from 
the  edge.  The  motion  should  be  practically  the  same  as  that  employed  in 
stropping  a  razor.  If  several  instruments  of  the  same  pattern  are  included 
in  the  lot  sterilized,  it  should  be  noted  that  serial  numbers  are,  or  should 
be,  stamped  upon  the  blades  of  each,  that  the  pairs  or  parts  may  not  be 
mismated  when  they  are  again  reunited  for  use.  For  instance,  an  artery 
forceps  is  found  to  bear  the  serial  number  9.  An  examination  should 
reveal  the  fact  that  both  blades  are  stamped  "9."  This  will  enable  the 
assistant  to  properly  pair  the  blades  after  separation. 

Preceding  an  operation,  instruments  should  be  re-sterilized.     In  such 


STERILIZATION    OF    SUTURES    AND    LIGATURES 


171 


cases,  after  removal  from  the  sterilizer,  they  may  be  arranged  in  trays 
filled  with  antiseptic  solutions,  or  they  may  be  placed  upon  dry,  sterilized 
towels  in  such  a  manner  that  the  sides  and  ends  of  the  towels  are  folded 
over  the  instruments,  thus  protecting  them  from  air  contact.  The  high 
temperature  of  the  instruments  when  removed  from  the  boiling  water  will 
soon  dry  them,  so  that  it  is  not  necessary  to  run  the  risk  of  contamination 
by  wiping. 

Sterilization  of  Sutures  and  Ligatures. 

The  proper  sterilization  of  the  material  used  in  suturing  and  ligating 
is  a  question  that  has  commanded  the  attention  of  almost  every  operator 
of  note  since  the  principles  of  surgical  infection  were  first  made  known  to 
the  world.  The  experiments  that  have  been  directed  toward  securing 
perfect  methods  have  been  almost  numberless,  many  surgeons  having 
given  years  of  tireless  devotion  toward  the  solution  of  this  problem.  The 
different  methods  advocated  by  able  operators  during  the  past  ten  years 
for  the  sterilization  of  catgut  alone  would  fill  a  moderate  sized  volume, 
and  while  it  is  not  claimed  that  to-day  absolutely  ideal  methods  have  been 
found  that  will  produce  sutures  both  aseptic  and  antiseptic,  yet  so  far  have 
the  various  methods  been  perfected  that  if  carried  out  perfectly,  they  will 
provide  the  surgeon  with  sutures  and  ligatures  from  the  use  of  which  there 


cA 


:•-  * 


Figure  327.     Metal  Racks,  in  Which  to  Place  Knives  While  Being  Sterilized  by  Boiling 

will  be  practically  no  danger  of  direct  infection.     The  principal  materials 
used  for  suturing  and  ligating,  all  of  which  require  sterilization,  are : 
Catgut,  kangaroo  tendon,  silkworm  gut,  horse  hair  and  silver  wire. 

Catgut. 

As  this  material  while  in  process  of  manufacture  undergoes  more  or 
less  maceration  and  partial  decomposition,  it  becomes  infected  with  innu- 
merable pathogenic  bacteria. 

As  anthrax  is  a  prevalent  disease  among  sheep,  it  follows  that  quite  a 
percentage  of  the  catgut  in  the  market  is  infected  with  this  form  of  bac- 
teria. Owing  to  the  peculiar  nature  of  this  substance  it  is  impossible  to 
sterilize  it  with  steam  or  hot  water,  because  these  agents,  by  softening  the 
strands,  convert  them  into  a  plastic  mass  unfit  for  suturing  or  ligating  pur- 


172  STERILIZATION. 

poses.  Resort  must,  therefore,  be  had  to  some  method  which  will  secure 
sterilization  without  materially  softening  the  structure  of  the  gut.  Surgi- 
cal sterilization  may  be  secured  by  boiling  in  alcohol  or  other  fluid  not 
absorbed  by  the  gut,  by  chemical  sterilization  or  by  dry  heat  sterilization. 
The  process  of  sterilizing  catgut  by  boiling  in  alcohol  usually  consists 
in  winding  the  gut  upon  small  glass  reels  or  cylinders,  placing  these  in  a 
bottle,  ignition  tube,  or  other  suitable  receptacle,  filling  the  latter  suffi- 
ciently to  submerge  the  catgut,  placing  the  same  in  a  water  bath  and  heat- 
ing the  latter  until  the  liquid  boils.  This  process  will  destroy  all  forms  of 
pathogenic  bacteria.  In  order  to  destroy  the  spores,  if  any  be  present,  it 
is  necessary  to  continue  this  process  for  three  consecutive  days,  after  which 
it  is  fair  to  presume  that  the  product  is  surgically  sterile. 

Chemical  sterilization  of  catgut  may  be  secured  by  a  number  of  proc- 
esses, Von  Bergmann's  method  being  more  generally  employed.  It 
consists  in  sterilizing  a  container  by  heat,  in  which  the  catgut,  in  order  to 
free  it  from  fat,  after  being  wound  on  glass  spools  or  bobbins,  is  immersed 
for  twenty-four  hours  in  sulphuric  ether.  The  ether  is  then  poured  off 
and  replaced  by  the  following  solution: — 

Alcohol  800  parts,  distilled  water  200  parts,  and  corrosive  sublimate 
10  parts. 

After  24  hours  this  solution  will  become  turbid,  when  it  should  be 
poured  off  and  replaced  with  a  fresh  lot  of  the  same  solution,  repeating 
the  process  until  the  catgut  has  passed  through  three  different  lots  of  the 
same  solution.  It  may  then  be  removed  and  permanently  stored  in 
absolute  alcohol. 

Formaldehyde  Catgut. 

The  discovery  of  the  germicidal  properties  of  formaldehyde  when 
applied  to  surgery  is  scarcely  less  important  than  that  announcing  the  fact 
that  catgut,  after  being  subjected  to  the  action  of  this  agency,  may  be  boiled 
in  water  under  certain  conditions  without  impairing  its  tensile  strength. 
This  process  not  only  supplies  aseptic  catgut,  but  enables  the  operator  to 
impart  to  it  mild  antiseptic  properties,  thus  furnishing  what  the  world  has 
for  years  been  seeking,  a  strong,  supple,  antiseptic,  absorbable  suture. 

This  condition  may  be  secured  either  by  exposing  the  gut  to  the  action 
of  formaldehyde  gas  or  by  soaking  it  in  an  impregnated  solution.  Dudley 
advises  that  the*  gut  after  winding  be  first  immersed  in  ether  for  1 2  hours 
that  it  may  be  deoleated.  He  claims  that  gut  prepared  in  the  manner 
above  described  has  been  found  to  resist  absorption  as  long  as  chromicized 
gut,  and  that  stitches  have  been  found  intact  six  weeks  after  operation. 
The  effect  of  this  exposure  is  not  so  much  to  destroy  bacterial  deposits  as 
to  harden  the  tissue  structure  of  the  material,  that  it  may  withstand  the 
action  of  boiling  water  without  impairing  its  usefulness.  This  boiling 
process  may  be  repeated  without  much  injury  to  the  material. 

In  carrying  out  this  process  it  is  only  necessary  that  the  catgut  be 
wound  upon  suitable  reels,  that  during  immersion  in  the  formaldehyde 
solution  or  afterward  during  the  boiling  process,  it  may  not  contract, 
untwist  or  otherwise  change  its  physical  condition  and  thereby  lessen  its 
tensile  strength. 

As  ordinarily  employed,  the  catgut  is  wound  upon  glass  plates  or  small 
cylinders,  the  ends  of  each  strand  being  firmly  secured.  That  the  formalde- 
hyde solution  and  the  boiling  water  may  have  free  access  to  all  portions 
of  the  gut,  only  one  layer  should  be  wound  on  the  reel. 


STERILIZATION    OF    SUTURES    AND    LIGATURES.  173 

The  solution  employed  is  usually  from  2  to  4  per  cent,  and  the  time  of 
immersion  about  48  hours. 

This  must  be  followed  by  a  de-formalizing  process,  or  one  in  which  the 
catgut  is  rendered  free  from  the  formaldehyde.  It  may  be  de-formalized 
by  placing  it  in  a  jar  and  conducting  a  stream  of  water  by  means  of  a  rub- 
ber hose  to  the  bottom  of  the  jar,  allowing  the  surplus  to  run  out  at  the 
open  top.  This  should  be  continued  for  from  12  to  24  hours,  after  which 
the  plates  or  cylinders  of  catgut  may  be  transferred  to  a  sterilizer  and 
boiled  without  injuring  the  tensile  strength  of  the  material.  This  boiling 
process  may  be  continued  for  20  or  more  minutes,  at  the  end  of  which  time 
the  gut  will  be  found  surgically  sterile. 

After  sterilization  the  catgut  may  be  stored  by  immersion  in  a  mixture 
of  absolute  alcohol  95  parts,  glycerine  5  parts,  corrosive  sublimate  ^  of 
i  part.  Senn  advises  the  substitution  of  10  per  cent,  of  iodoform  for  the 
corrosive  sublimate,  claiming  for  it  special  antiseptic  properties.  Gold- 
spohn  instead  of  water,  boils  the  formaldehyde  gut  in  a  solution  of  pyok- 
tanin  (methylene-blue)  i  to  1000,  preserving  the  sutures  in  commercial 
alcohol,  drawing  the  latter  direct  from  the  original  barrel  into  the  package 
without  the  use  of  graduates,  measures  or  funnels. 

Dry  Heat  Sterilization  of  Catgut. 

Many  experimenters  have  said  that  the  difficulties  encountered  in  the 
dry  heat  sterilization  of  catgut  were  due  either  to  the  amount  of  natural 
fat  incorporated  in  the  tissues  of  the  gut,  or  to  the  water  contained  in  it, 
and  that  in  the  employment  of  dry  heat  a  sort  of  cooking  process  ensues, 
the  result  of  which  is  to  render  the  material  so  friable  as  to  be  unfit 
for  use. 

If  these  were  the  difficulties,  they  have  been  in  a  great  measure  over- 
come by  the  employment  of  the  system  first  devised  by  Benckiser  and 
Reverdin,  as  is  evidenced  by  the  experiments  of  Benckiser,  Reverdin  and 
Boeckmann.  This  method  consisted  at  first  in  the  gradual  application  of 
dry  heat,  commencing  at  normal  temperature  and  increasing  slowly  for 
three  hours,  at  the  end  of  which  time  the  temperature  should  be  about 
284°  Fahr.  As  a  result,  the  gut  parts  with  its  contained  fat,  the  latter 
being  absorbed  by  a  paper  wrapper  previously  applied.  Under  the  influ- 
ence of  the  gradually  increasing  heat,  the  water  is  also  evaporated,  so  that 
when  the  maximum  temperature  is  reached,  the  substance  is  both  deoleated 
and  dehydrated.  Under  these  conditions  a  temperature  of  284°  to  300° 
Fahr.  may  be  maintained  for  three  consecutive  hours  without  materially 
lessening  the  tensile  strength  of  the  gut. 

The  objections  to  the  adoption  of  this  system  were  two-fold ;  first,  the 
difficulty  of  securing  this  result  without  undue  labor  and  expense,  and 
second,  a  general  belief  that  catgut  so  sterilized  would  lose  so  much  of  its 
tensile  strength  as  to  render  it  practically  worthless. 

The  first  objection  has  been  overcome  by  Boeckmann,  as  a  technique  has 
been  so  perfected  that  the  process  can  be  easily  carried  out  by  the  average 
practitioner,  and  that  any  good  dry  heat  sterilizer  may  be  employed. 

According  to  his  methods  the  catgut  to  be  sterilized  is  cut  into  sutures 
of  the  required  length ;  each  is  wrapped  in  a  piece  of  paraffin  paper  and  the 
package  tightly  sealed  in  a  small  envelope.  These  are  then  placed  on  edge 
in  a  special  box  and  transferred  to  a  sterilizer.  This  box  should  be  con- 
structed with  a  perforated  cover  and  a  wire  gauze  bottom.  The  opening 
in  the  top  of  the  catgut  box  should  be  so  arranged  that  a  thermometer 


174  STERILIZATION. 

may  be  introduced  directly  into  the  box  from  the  outside  of  the  instru- 
ment that  the  temperature  may  at  all  times  be  noted.  To  insure  perfect 
sterilization  the  temperature  should  be  taken  two  to  four  times  per  hour 
during  the  continuance  of  the  process.  Owing  to  the  necessity  for  a 
longer  exposure  when  sterilizing  the  heavier  sizes  of  gut,  it  is  advised  that 
No.  5  and  all  larger  sizes  be  submitted  to  this  process  a  second  time — say 
forty-eight  hours  after  the  first. 

The  result  as  before  stated  is  perfect  surgical  sterilization.  The  outside 
of  the  envelopes  will  doubtless  become  infected  by  handling,  but  when 
wanted  for  use,  an  attendant  has  only  to  tear  open  the  envelope  and  drop 
the  sterilized  contents  into  the  hands  of  the  surgeon  or  his  assistant. 

The  author,  in  order  to  determine  whether  or  not  the  second  objection 
before  mentioned  was  well  founded,  submitted  specimens  of  catgut  to 
the  following  tests:  10  pieces  of  German  catgut  No.  6,  each  six  feet  in 
length,  were  selected  and  numbered  consecutively  from  i  to  10,  each  being 
labeled  at  three  points,  at  both  ends  and  in  the  center.  These  pieces 
were  then  cut  into  three  sutures  2  feet  in  length,  resulting  in  three  of  each 
number.  One  set  of  sutures,  those  cut  from  the  center  of  each  piece,  were 
then  tested  to  ascertain  their  tensile  strength  by  a  system  of  weights  and 
scales.  Their  breaking  tensile  strength  was  found  to  vary  from  26  pounds 
to  32  pounds  and  6  ounces,  as  shown  by  the  annexed  table : 

A  second  lot  of  10  sutures  were  then  sterilized  by  the  Schimmelbusch 
process,  subjected  to  the  same  test  as  above  mentioned  and  the  breaking 
tensile  strength  found  to  vary  from  21  pounds  and  10  ounces  to  27  pounds 
and  14  ounces. 

The  remaining  10  pieces  were  subjected  to  the  Boeckmann-Benckiser 
system  of  dry  heat  sterilization,  after  which  the  breaking  tensile  strength 
was  found  to  vary  from  20  pounds  to  29  pounds  and  4  ounces. 

Raw  Catgut.  Alter  Sterilization  by        After  Sterilization  by 

Boeckmann  Process.          Schimmelbusch   Process. 

Strand  No.  i,  27  Ibs.  27  Ibs.  12  oz.  27  Ibs.  14  oz. 


2,  26     6  oz.  24  '  26 

3,  28  "  10  "  23  "  24 

4,  32     6"  26  "  5  "  23 

5,  27  27  '  4  '  23 

6,  31  "  10  "  29  "  4  "  26 

7,  28  "  4  "  20  "  23 

8,  26  "  22  "  12  "  21 

9,  26  '  12  "  25  '  10  "  27 

10,  30  "  13  "  23  "  12  "  24 


12 

6 

12 

6 
6 


249H 

Table  showing  breaking  tensile  strength  of  catgut  before  and  after  sterilization. 

It  will  be  seen  by  consulting  the  above  table  that  the  combined  weight 
sustained  by  the  ten  raw  sutures  was  284^1  pounds,  or  an  average  of  about 
28T\  pounds  each.  The  weight  sustained  by  the  ten  sterilized  by  the 
Schimmelbusch  process  was  248^  pounds,  or  an  average  of  nearly  24^ 
pounds  each,  while  that  subject  to  the  Boeckmann-Benckiser  process  was 
249 1  $  pounds,  or  an  average  of  nearly  25  pounds  each. 

It  is  evident  from  this  single  experiment  that  there  is  practically  no 
difference  resulting  from  the  use  of  the  Schimmelbusch  and  Boeckmann- 
Benckiser  systems,  as  a  slight  variation  in  a  single  suture  might  have 
resulted  in  one  or  the  other  showing  a  slight  advantage. 


STERILIZATION    OF    SUTURES    AND    LIGATURES. 


175 


It  requires  little  argument  to  demonstrate  the  superiority  of  the  dry 
heat  system  over  other  methods.  As  the  sutures  require  no  vessels  or 
containers  in  which  to  preserve  them,  they  can  be  stored  or  transported  in 
a  small  space.  As  they  are  sealed  in  small  envelopes,  they  may  be  kept 
indefinitely  without  danger  of  infection.  As  no  expensive  chemicals  are 
necessary,  either  in  the  process  of  sterilization  or  storage,  the  cost  of  prep- 
aration is  reduced  to  a  minimum. 

Kangaroo  Tendons. 

The  sterilization  of  tendon  ligatures  is  a  more  simple  process  than  that 
involved  in  the  production  of  aseptic  catgut.  This  is  particularly  true  of 
kangaroo  tendons.  If  taken  from  a  freshly  killed  animal  and  at  once  sun- 
dried  ;  if  properly  stored  and  not  allowed  to  become  moist,  they  are  not 
likely  to  be  infected  with  any  but  pyogenic  bacteria,  and  then  only 
superficially. 

The  method  of  preparation  as  described  by  Marcy  consists  in  first  soak- 
ing the  tendons  in  a  solution  of  i  to  1000  bichloride  of  mercury  until 
supple.  The  tendons  are  then  separated  and  stored  length-wise  between 
sterilized  towels  and  dried;  they  are  rendered  aseptic  by  washing  in  a 


Figure  328.    Schimmelbusch's  Ligature  Box. 

solution  of  formaldehyde  washed  in  sterilized  water  and  are  then  chromicized 
in  a  5  per  cent,  solution  of  carbolic  acid  to  which  has  been  added  ?-<jV0-  Part  °f 
purified  chromic  acid.  To  avoid  precipitation  of  the  chromic  acid,  the  ten- 
dons should  be  immersed  immediately  on  the  preparation  of  the  fluid. 
The  length  of  immersion  the  tendons  will  require  will  depend  somewhat 
upon  their  size.  The  process  should  be  continued  until  they  are  of  a  dark 
golden  color,  after  which  they  should  be  dried  between  sterilized  towels 
and  stored  in  carbolized  oil.  The  sutures  improve  by  age  when  kept  in  oil. 

Silk. 

This  substance,  either  twisted  or  braided,  may  be  sterilized  either  with 
the  dressings  or  instruments.  If  placed  with  the  dressings  and  exposed  to 
a  proper  steam  current  for  20  minutes,  or  if  immersed  in  boiling  water 
with  the  surgical  instruments  for  two  or  more  minutes,  it  will  be  free  from 
disease  germs. 

Among  the  many  appliances  designed  for  the  storing  of  silk  during  and 
following  sterilization,  none  have  been  more  widely  recommended  than 


176  STERILIZATION. 

the  apparatus  designed  by  Schimmelbusch  and  shown  by  figure  328.  It  con- 
sists of  a  small  metal  box  with  folding  cover,  upon  one  side  of  which  is  a  second 
anterior  wall  secured  to  the  base  by  a  suitable  hinge.  The  interior  of  the 
box  contains  three  upright  shafts  upon  which  revolve  suitable  rollers  on 
which  the  silk  may  be  wound.  The  rollers,  instead  of  being  solid,  are 
composed  of  a  framework  of  short  steel  rods,  united  at  their  ends  by  circu- 
lar metal  plates  thus  facilitating  the  introduction  of  steam  into  and  through 
the  interior  of  the  mass.  The  inner  of  the  two  lateral  walls  shown  upon 
one  side  is  slotted  and  perforated,  that  the  ends  of  the  silk  passing  from 
the  rollers  above  mentioned  may  remain  outside  of  the  box  proper,  being 
held  in  place  by  the  closing  of  the  hinged  external  wall  previously  referred 
to.  If  the  cover  be  thrown  back  and  the  box  placed  in  a  steam  sterilizer 
for  20  minutes,  the  container  and  contents  may  be  thoroughly  disinfected. 
Upon  removal  and  closure  of  the  box  its  contents  may  be  maintained  in  an 
aseptic  condition  for  a  considerable  length  of  time. 

Silkworm  gut,  horse  hair  and  silver  wire  may  be  sterilized  in  the  same 
manner  as  ordinary  silk,  no  special  directions  being  necessary. 

No  better  method  for  the  sterilizing  and  storage  of  ligatures  has  been 
devised  than  the  system  involving  the  use  of  reels,  bobbins  and  ignition 
tubes.  These  may  be  purchased  in  such  combinations  that  the  surgeon 
may  at  all  times  be  provided  with  reels  and  bobbins  that  will  fit  the  tubes 
perfectly.  The  latter,  if  properly  made,  consist  of  a  strong  quality  of 
glass  carefully  annealed,  that  they  may  withstand  the  temperature  neces- 
sary for  sterilization.  The  ligatures 'may  be  wound  upon  the  bobbins,  the 
latter  placed  in  the  ignition  tubes  and  these  tubes  transferred  to  a  steam 
sterilizer  where,  resting  in  a  horizontal  position,  they  may  be  sterilized  in 
the  usual  manner.  The  necessity  for  placing  these  tubes  upon  their  sides 
will  be  recognized  when  it  is  understood  that  if  in  an  upright  position,  it 
would  be  impossible  for  the  steam  to  force  the  air  out  of  the  tube  and 
replace  it.  If  the  tubes  be  placed  with  the  mouth  downward,  while  they 
would  fill  with  steam,  it  would  be  impossible  to  thoroughly  dry  out  the 
ligatures  before  taking  the  tubes  from  the  sterilizer,  while  if  resting  hori- 
zontal, steam  will  enter  the  tubes,  filling  them  to  a  state  of  complete  sat- 
uration, displacing  all  air,  in  which  condition  all  moisture  may  be  expelled 
and  the  tubes  removed  from  the  sterilizer  with  absolutely  dry  ligatures. 
After  removal  no  other  stoppers  should  be  used  in  these  tubes  excepting 
ordinary  non-absorbent  cotton.  If  absorbent  cotton  be  used,  it  will  absorb 
moisture  from  the  air,  thus  supplying  a  medium  for  the  cultivation  of  micro- 
organisms. 

The  care  and  storage  of  sterilized  ligatures  is  further  discussed  in  the 
chapter  devoted  to  sutures,  to  which  the  reader  is  referred. 

Sponges. 

As  sponges  will  not  withstand  the  effects  of  sterilization  by  steam  or 
boiling  water,  it  is  necessary  to  employ  some  form  of  chemical  disinfection 
or  dry  heat. 

While  sponges  will  withstand  a  degree  of  dry  heat  sufficient  for  steril- 
ization provided  they  are  perfectly  dry  when  placed  in  the  apparatus,  this 
method  is  but  little  employed. 

The  best  plan  suggested  for  this  purpose  is,  we  believe,  that  devised  by 
Schimmelbusch,  which  is  in  brief  as  follows: 

All  foreign  substances  so  far  as  possible  are  first  removed  from  them. 
If  they  have  not  been  previously  employed  in  surgery,  all  pieces  of  shells 


STERILIZATION    OF    SPONGES    AND    DRESSINGS.  177 

should  be  cut  (not  torn)  from  them  and  the  sand  removed  by  beating  them 
thoroughly  with  a  stick.  Continued  soaking  in  cold  water  should  then 
follow,  during  which  time  they  should  be  frequently  squeezed  dry  and  as 
often  allowed  to  refill.  This  imparts  to  the  sponge  its  full  degree  of  elas- 
ticity. They  should  then  be  wrapped  in  a  linen  towel  or  placed  in  a  special 
sack  and  immersed  in  a  large  sized  boiler  containing  a  i  per  cent,  hot  soda 
solution.  As  previously  stated,  sponges  will  not  tolerate  boiling,  as  it 
causes  them  to  shrink  and  harden;  consequently  the  reservoir  must  be 
removed  from  the  fire  before  the  immersion  of  the  sponges.  Surgical' ster- 
ilization will  result  if  the  sponges  be  maintained  in  the  hot  solution  for  from 
20  to  30  minutes.  After'  removal  from  this,  and  while  still  inclosed  in  a 
towel  or  sack,  they  may  be  cleansed  from  the  soda  solution  by  immersion 
and  washing  in  sterilized  water,  after  which  they  may  be  preserved  in  an 
antiseptic  solution.  If  bleaching  is  thought  necessary,  before  placing  in 
the  boiling  solution,  they  may  be  immersed  in  a  solution  of  permanganate 
of  potassium  i  to  500.  After  pressing  out  all  surplus  fluid,  they  may  then 
be  transferred  to  a  i  per  cent,  solution  of  sulphate  of  sodium  to  which  is 
added  8  per  cent,  of  pure  muriatic  acid,  in  which  they  may  be  bleached  as 
white  as  desired.  As  this  process  destroys  the  strength  of  the  fiber  in  pro- 
portion to  the  length  of  time  of  immersion  in  the  acid  solution,  care 
should  be  exercised  that  they  may  be  retained  no  longer  than  is  necessary 
to  change  them  to  the  color  desired.  They  may  be  permanently  preserved 
in  a  5  per  cent,  solution  of  carbolic  acid. 

Dressings,  Etc. 

Dressings  should  be  sterilized  by  some  one  of  the  steam  systems  previ- 
ously described.  If  an  under-steam  sterilizer  be  used,  care  should  be  exer- 
cised in  securing  an  even  distribution  of  packages.  Tight  rolling  and  tight 
packing  of  porous  materials  should  be  avoided.  Currents  of  under-steam, 
like  currents  of  air,  seek  channels  of  least  resistance,  and  unless  this  pre- 
caution be  observed,  imperfect  sterilization  will  result.  While  this  does 
not  apply  with  equal  force  to  an  over-steam  sterilizer,  yet  it  will  be  better 
not  to  pack  articles  too  closely  or  to  roll  them  too  tightly,  because  the  more 
space  they  occupy  the  more  readily  will  the  steam  penetrate  them. 

Absorbent  gauze,  before  sterilization,  should  be  cut  into  squares  or 
packages  of  about  the  size  that  will  be  required  for  application.  These 
squares  may  be  loosely  folded  once  or  even  twice,  and  placed  in  jars  or 
other  carriers.  They  may  be  more  easily  separated  for  use  if  layers  of 
absorbent  cotton  be  placed  between  each  package.  This  will  facilitate 
handling  and  assist  somewhat  in  preventing  air  contamination. 

Bedding,  clothing,  etc. ,  can  be  sterilized  only  by  steam  and  for  this  pur- 
pose we  recommend  either  an  over-steam  system  or  a  high  pressure 
apparatus,  the  latter  being  preferable. 

Pressure  steam  is  particularly  applicable  for  disinfecting  beds,  clothing, 
dressings,  and  all  articles  of  considerable  bulk.  Rolls  of  woolen  blankets, 
for  instance,  can  not  be  well  sterilized  by  any  other  method  without  injury. 
Hot  air  will  not  thoroughly  penetrate  large  bundles  of  woven  fabrics  in  a 
reasonable  time.  The  internal  temperature  of  such  packages  can  only  be 
raised  to  the  desired  point  by  some  form  of  saturated  steam.  Over-steam 
may  be  utilized  for  this  piirpose,  though  to  hardly  so  good  advantage  as 
high  pressure  steam. 

12 


CHAPTER  VIII. 


ANESTHESIA. 

Anesthesia  for  the  prevention  of  pain  during  examinations  or  the  con- 
duct of  surgical  operations  may  be  either  general  or  local. 

GENERAL  ANESTHESIA. 

General  anesthesia  is  produced  by  the  administration  of  certain  agents 
called  anesthetics.  The  selection  of  the  agent  to  be  employed  should  be  a 
simple  proposition  involving  only  the  safety  of  the  patient.  The  questions 
of  cost,  convenience,  wishes  of  patient,  or  saving  of  time  are  practically  of 
no  importance. 

Great  care  is  advised  in  the  sterilization  of  all  instruments  and  appliances 
used  for  anesthetizing  purposes.  Infection  has  been  traced  to  this  source, 
and  its  importance  should  not  be  underestimated.  It  is  better  that  mouth 
gags,  tongue  forceps,  inhaling  apparatus,  and  articles  of  this  class  be  not 
used  indiscriminately  upon  patients,  and  it  is  to  be  hoped  that  the  hereto- 
fore common  practice  of  using  these  instruments  first  upon  one  patient  and 
then  upon  another  without  sterilization  or  cleansing  be  discontinued. 


Figure  329.    Allis'  Ether  Inhaler,  with  Detachable  Metal  Cover. 

The  principal  methods  are  by  inhalation  of  ether,  chloroform  and  nitrous 
oxide,  either  alone  or  in  combination  with  air,  oxygen,  or  some  similar 
variety  of  Schleich's  solutions. 

The  apparatus  usually  required  consists  of  an  inhaler  for  administration 
of  the  anesthetizing  agent,  a  tongue  forceps  for  holding  the  tongue, 
a  mouthgag  for  opening  or  holding  open  the  mouth,  and  sponges  and  a 
sponge  holder  for  removing  secretions  from  the  throat. 

Ether  Inhalers. 

Ether  may  be  administered  from  a  saturated  sponge,  cloth  or  special 
apparatus  constructed  for  the  purpose.  Such  appliances  are  called  inhalers. 
They  usually  consist  of  a  frame,  cover  or  support  for  a  suitable  woven 
fabric,  sponge  or  other  absorbing  substance,  by  which  the  ether  may  be 
brought  into  direct  contact  with  the  inspired  air  and  so  far  as  possible  ex- 
cluded from  evaporation. 

178 


ETHER    ANESTHESIA. 


179 


Allis'  Inhaler,  as  illustrated  in  figure  329,  consists  of  a  metallic  frame- 
work large  enough  to  cover  the  lower  portion  of  the  face  and  so  fenestrated 
as  to  admit  of  the  introduction  of  a  large  number  of  cloth  partitions. 
These  partitions  are  formed  from  a  gauze  bandage  by  weaving  the  cloth 
back  and  forth  through  the  fenestrae  in  the  sides  of  the  frame.  Although 
the  instrument  is  only  about  4  inches  in  length  and  from  2  to  3  in  width,  it 
requires  about  three  yards  of  gauze  bandage  to  form  the  partitions. 
The  whole  is  surrounded  by  a  nickel-plated  cover  held  in  place  by  suitable 
spring  clips.  This  arrangement  provides  an  instrument  durable,  portable, 
inexpensive,  and  easily  sterilized.  One  end  of  the  external  covering  is  so 
arranged  as  to  fit  closely  the  contour  of  the  face.  The  apparatus  allows  the 
free  admission  of  air  from  above,  and  as  the  evaporating  surface  is  large, 
rapid  vaporization  and  etherization  follows.  The  quantity  of  ether  may 
be  replenished  as  fast  as  desired  by  pouring  it  upon  the  outer  surface  of  the 


ana 


Figure  330.    Fowler's  Modific 
Allis'  Ether  Inhaler. 


jn  of 


Figure  331.    Clover's  Ether  Inhaler. 


exposed  gauze  edge,  without  removing  the  inhaler  from  the  face  of  the 
patient.  After  use  the  gauze  may  readily  be  replaced  by  an  assistant.  A 
metal  plate  for  threading  purposes  accompanies  each  instrument. 

Fowler's  Modification  of  Allis'  Inhaler,  as  pictured  by  figure  330,  is  par- 
ticularly adapted  for  use  in  an  emergency  bag.  Its  principal  feature  is  a 
jointed  arrangement  by  which  it  may  easily  be  folded  into  a  flat,  compact 
form.  In  this  device  the  oval  pattern  previously  described  is  replaced  by 
a  diamond  shaped  frame,  but  the  arrangement  of  the  gauze  partitions  are 
almost  identical  with  that  of  the  instrument  designed  by  Allis.  When  ex- 
panded, the  instrument  is  3  inches  wide,  with  an  extreme  length  of  6%" 
inches.  When  folded  flat,  it  is  7  inches  in  length  by  about  ^  inch  in 
thickness. 

Clover's  Inhaler,  as  represented  in  figure  331,  consists  of  a  cylindrical 
receiver,  surmounted  by  a  dome-shaped  chamber,  the  whole  arranged 
in  such  a  manner  that  the  amount  of  ether  inhaled  with  each  inspira- 
tion may  be  regulated  at  will.  A  tube  about  one  inch  in  diameter  with 
suitable  openings  passes  entirely  through  the  receiver.  A  mouth-piece 
cushioned  with  an  inflated  rubber  rim  is  attached  to  the  lower  end  of  the 
tube,  the  inflatable  portion  being  so  arranged  that  air  may  be  forced  into  it 
to  maintain  its  annular  form.  At  the  upper  end  of  the  cone  is  attached  a 


180 


ANESTHESIA. 


tube  bent  at  right  angles,  over  the  distal  end  of  which  the  neck  of  a  rubber 
gas  bag  is  tightly  drawn.  By  a  peculiar  adjustment  of  the  inner  tube  and 
a  series  of  openings,  the  amount  of  ether  being  inhaled  is  graduated.  A 
small  indicator,  which  revolves  with  the  mouth-piece,  notes  the  relations  of 
the  parts  to  each  other.  Upon  the  outer  surface  of  the  receptacle  the  fig- 
ures o,  i,  2,  3  and  the  letter  "F"  appear.  When  the  indicator  points  at  o, 
no  ether  is  inhaled;  when  at  i,  it  shows  that  one-quarter  of  the  air  inspired 
passes  through  the  ether  chamber;  at  2,  that  one-half  of  the  air  so  passes; 
at  3,  that  the  quantity  passed  through  the  chamber  is  three-fourths,  and  at 
F,  that  no  air  is  admitted  which  does  not  pass  through  the  ether  chamber. 
The  instrument  has  an  extensive  use  in  London,  where  it  originated,  and  is 
there  employed  almost  to  the  exclusion  of  other  patterns.  It  is  claimed 
that  with  the  Clover  inhaler  a  patient  may  be  anesthetized  in  a  shorter  time 
and  with  greater  ease  than  with  any  other  form  of  apparatus;  that  the 
dangers  of  etherization  are  not  as  great;  that  the  quantity  of  ether  em- 
ployed is  diminished ;  that  the  consciousness  is  recovered  more  quickly,  and 
that  the  shock  to  the  nerve  centers  is  not  so  great. 

The  Plain  Ether  Drop  Bottle,  pictured  in  figure  335,  is  a  graduated  bot- 
tle with  cork  and  sigmoid  shaped  outlet  tube,  the  latter  of  fine  caliber.  The 
end  of  the  tube  within  the  bottle  is  curved  until  it  nearly  touches  the  bottle 
side,  while  the  external  tip  curves  in  an  opposite  direction.  A  cap  covers 
the  latter  to  prevent  evaporation  when  the  tube  is  not  in  use. 

Chloroform  Inhalers. 

Chloroform,  like  ether,  may  be  administered  by  simply  dropping  a  small 
quantity  upon  a  napkin,  sponge  or  other  absorbing  substance,  or  by  means 
of  some  special  form  of  inhaler. 


Figure  332.     Esmarch's  Chloroform  Inhaler. 


Figure  .333.    Esmarch's   Chloroform  Inhaler 
with  Tongue  Forcepsin  Leather  Case. 

Esmarch's  Chloroform  Inhaler,  as  depicted  in  figure  332,  consists  of  a 
simple  wire  frame  shaped  to  fit  the  contour  of  the  face  around  the  mouth 
and  nose ;  one  end  of  the  frame  is  curved  to  form  a  handle  by  which  the 
apparatus  may  be  held  in  place.  Over  this  framework  is  stretched  a  knit- 
ted or  woven  fabric,  the  texture  of  which  is  of  such  a  nature  as  to  admit  of 
the  free  passage  of  air.  The  chloroform  may  be  dropped  upon  the  mask 


CHLOROFORM    ANESTHESIA. 


181 


from  a  small  flask  containing  a  cork  through  which  a  suitable  drop  tube  is 
passed.  This  tube  reaches  nearly  to  the  bottom  of  the  bottle  and  is  curved 
so  that  all  of  the  chloroform  in  the  container  may  be  dropped  from  the  tube. 
The  mouth  of  this  drop  tube  is  closed  by  a  suitable  cap  that  the  chloro- 
form vapor  may  not  escape  from  the  flask  when  not  in  use.  Air  to  replace 
the  chloroform  is  admitted  by  a  second  tube  also  passing  through  the  cork. 
The  apparatus  is  safe,  efficient,  economical,  and  may  be  purchased  at  a 
moderate  price.  When  desired,  several  cloth  covers  may  be  procured  with 
each  instrument.  These  may  be  sterilized  and  kept  ready  for  use. 

The  apparatus  of  Esmarch  may  be  procured  in  combination  with  a 
tongue  forceps,  as  shown  in  figure  333,  the  whole  apparatus  being  included 
in  a  solid  leather  case  for  transportation. 


Figure  334.     Schimmelbusch-Esmarch 
Inhaler. 


Figure  335.    Plain  Ether  Drop  Bottle. 


Schimmelbusch's  Modification  of  Esmarch's  Inhaler,  as  shown  .in  figure 
334,  consists  of  a  framework,  provided  with  a  handle,  over  which  a  cover  of 
any  material  may  be  stretched  and  firmly  held  in  place.  Usually  a  number 
of  layers  of  absorbent  gauze  are  utilized  for  this  purpose.  The  framework 
consists  of  a  flat  ring  formed  to  fit  the  contour  of  the  face.  This  ring  is 
grooved  to  receive  a  movable  wire,  hinged  in  such  a  manner  that  when 
snapped  into  place,  it  will  firmly  hold  the  cover  in  position.  Two  bows, 


Figure  336.    Pierepont's  Folding  Chloroform  Inhaler.  Figure  337.    Hahn's  Drop  Bottle. 

each  at  right  angles  with  the  other,  cross  the  ring  from  side  to  side.  These 
are  hinged  so  that  when  not  in  use,  they  may  be  folded  flat,  thus  rendering 
the  instrument  more  compact.  When  preparing  the  inhaler  for  use,  the 
bows  are  placed  in  an  upright  position  and  the  gauze  drawn  tightly  over 
them,  where  they  are  securely  fastened  by  the  clamp  before  mentioned. 
By  cutting  away  the  redundant  portions  of  the  cover,  the  apparatus  will 
present  a  neat  and  attractive  appearance.  Its  advantage  consists  in  the  ease 


182 


ANESTHESIA. 


•with  which  a  fresh  cloth  may  be  supplied  after  each  administration.  The 
advantages  of  this  should  be  appreciated,  because  after  use,  by  removing 
the  cover,  dipping  the  instrmnent  for  two  minutes  in  boiling  water  and 
supplying  a  fresh  gauze  cover,  an  aseptic  appliance  for  the  succeeding  case 
is  provided. 

Pierepont's  Inhaler,  illustrated  in  figure  336,  is  sufficiently  compact  to 
admit  of  its  being  carried  in  a  small  space.  It  consists  of  a  spiral,  com- 
pressible wire  cone,  so  constructed  that  it  may  readily  be  folded  flat  and 
then  locked  and  easily  sterilized.  It  may  be  rendered  suitable  for  use  by 
unclasping  the  locks,  permitting  the  cone  to  expand  and  binding  around  it 
a  sterilized  towel.  After  the  apparatus  has  been  utilized  for  the  anesthet- 
izing of  a  patient,  the  towel  may  be  removed,  the  instrument  immersed  for 
two  minutes  in  boiling  water,  after  which  a  second  sterilized  towel  may  be 
attached  and  an  aseptic  instrument  thus  prepared  for  the  next  patient. 


Figure  338.    Junker's  Chloroform  Inhaler. 

Hahn's  Drop  Bottle,  shown  in  figure  337,  consists  of  a  small  amber- 
colored  flask,  similar  to  that  in  use  in  connection  with  the  Esmarch  chloro- 
form inhaler.  Two  tubes  passing  through  the  metal  stopper  permit  the 
entrance  of  air  and  the  exit  of  the  chloroform.  The  passage  of  the  latter  is, 
however,  regulated  by  a  suitable  stop-cock,  under  control  of  a  thumb- 
piece,  by  which  it  may  be  closed  or  opened  at  will.  The  apparatus  will  be 
found  useful  in  connection  with  any  of  the  ordinary  open  masks  or  in  cases 
where  chloroform  is  administered  with  a  towel,  paper  cone,  or  similar 
appliance. 

Junker's  Chloroform  Inhaler,  as  depicted  in  figure  338,  consists  of  a  cone- 
shaped,  rubber  face  shield,  covering  the  mouth  and  nose,  provided  with  a 
respiratory  valve,  so  arranged  as  to  be  under  the  control  of  the  anesthet- 
izer.  This  mouth-piece  is  connected  by  means  of  a  rubber  tube,  with  a 
chloroform  bottle  having  a  capacity  of  about  two  ounces.  This  bottle  is 
covered  with  leather,  graduated  in  ounces  and  drachms,  and  provided  with 


CHLOROFORM    ANESTHESIA. 


183 


a  slot  in  the  leather  cover,  so  that  the  quantity  of  chloroform  in  the  bottle 
may  be  ascertained  at  any  time.  This  bottle  is  provided  with  an  air-tight 
stopper,  through  which  pass  two  tubes — an  inlet  and  outlet;  the  latter  is 
short,  extends  only  a  short  distance  below  the  under  surface  of  the 
stopper,  and  connects  with  the  face- shield.  The  inlet  tube  is  the  longer 
of  the  two ;  it  extends  to  the  bottom  of  the  bottle  and  is  connected  with 
a  double  bulb.  A  hook  attached  to  the  stopper  can  be  fastened  to  the 


Figure  339.    Side  Valve  Cylinders  for  Nitrous  Oxide. 

button-hole  of  the  anesthetizer's  coat  or  vest,  thus  enabling  him  to  ma- 
nipulate the  bulb  with  one  hand,  while  he  holds  the  face-shield  with  the  other. 

It  will  thus  be  seen  that,  by  pressing  the  bulb,  air  is  forced  through  the 
tube  into  the  chloroform,  whence  it  escapes  (impregnated  with  vapor), 
through  the  short  tube  into  the  face-shield  where  it  is  inhaled.  The 
amount  of  chloroform  incorporated  with  the  air  varies  with  the  quantity  con- 
tained in  the  bottle.  Thus,  assuming  the  cubic  contents  of  the  compressing 
bulb  to  be  about  four  and  one-quarter  cubic  inches,  if  eight  drachms  of 
chloroform  be  placed  in  the  bottle,  100  compressions  of  the  bulb  will  evap- 
orate about  120  minims  of  the  chloroform,  thus  diluting  the  chloroform,  as 
it  issues  into  the  face-shield,  about  i  to  1,000.  If  only  one  half  this  quantity 
of  chloroform  be  used,  about  go  minims  will  be  evaporated ;  while  if  but 
two  drachms  are  employed,  the  evaporation  falls  to  about  50  minims,  giving 
a  dilution  of  about  i  to  2,400. 

It  must  be  remembered  in  this  connection  that  this  applies  to  the  dilu- 
tion as  it  passes  from  the  bottle,  that  which  is  inhaled  being  from  four  to 
six  times  weaker  than  this. 


184 


ANESTHESIA. 


The  advantages  of  this  apparatus  are  many,  among  the  more  important 
of  which  are:  Its  great  economy;  there  is  no  external  evaporation;  a 
regular  and  uniform  dilution  is  obtained;  the  anesthetizer  has  complete 
control  over  the  supply;  greater  safety,  and  the  amount  of  chloroform 
administered  during  the  operation  may  be  ascertained  to  a  minim. 

Nitrous  Oxide. 

Nitrous  oxide  when  used  for  producing  general  anesthesia  may  be 
administered  pure  or  combined  with  air  or  oxygen. 

The  inhaling  apparatus  should  consist  of  a  suitable  shield  formed  to  fit 
the  face  closely,  the  shield  terminating  in  a  tube  to  which  is  attached  a 
rubber  gas  bag  having  an  opening  at  each  end ;  one  end  being  connected  with 
the  shield,  the  other  attached  to  a  rubber  tube  leading  to  the  metal  cylinder. 
A  small  stop-cock,  which  may  be  easily  operated  with  one  hand,  is  placed 
between  the  bag  and  face-shield,  that  the  flow  of  gas  from  the  bag  to  the 
patient  may  be  under  control.  Many  surgeons  prefer  a  face-shield  supplied 
with  a  valve,  so  that  when  desired,  inspirations  of  air  may  be  taken  by  the 


Figure  340.    Overholt's  Dropper  for  Schleich's  or 
Similar  Solution. 


Figure  341.    Stone's  Mask  for  Schleich's  Solution. 


Figure  342.  Compressed  Oxygen 
Tank. 


patient.  A  valve  "should  also  be  supplied  for  exhalation,  otherwise  the 
exhaled  gas  would  enter  the  rubber  bag,  there  to  be  again  inspired,  and 
thus  breathed  over  and  over  again.  An  arrangement  as  above  described, 
will  enable  the  patient  at  each  inspiration  to  breathe  in  a  quantity  of  fresh 
gas,  and  while  this  method  is,  of  course,  more  expensive,  it  is  for  many 
reasons  much  the  safer  plan. 

As  it  is  not  easily  transported  except  in  compressed  form  it  is  usually 
obtained  in  ordinary  tanks  similar  to  those  furnished  with  oxygen,  as  de- 
scribed by  figure  342,  or  in  special  cylinders  designed  expressly  for  anesthetic 
purposes.  In  either  case,  it  should  be  permitted  to  escape  only  through 
valves  that  are  under  quick  and  easy  control. 

The  Side  Valve  Cylinders  for  Nitrous  Oxide,  shown  by  figure  339,  are  of 
steel,  each  holding  25  gallons  of  free  gas.  From  Hewitt  we  learn  that  this 
form  of  tank,  with  the  necessary  connections,  have  been  perfected  by  Shep- 
pard,  and  that  it  embraces  all  necessary  features.  The  cylinders  as  illus- 
trated in  the  figure  are  connected  by  a  curved  brass  tube,  at  the  center  of 
which  a  junction  is  made  with  a  cloth-lined  hose  through  which  the  gas  is 
conducted  to  a  storage  bag  and  inhaler.  The  latter  is  usually  constructed 


SCHLEICH'S  SOLUTION  ANESTHESIA.  185, 

so  that  either  air  or  nitrons  oxide,  alone  or  in  any  combination,  may  be  in- 
haled by  the  patient  at  the  will  of  the  anesthetist.  A  circular  plate  is- 
provided  in  the  top  of  the  frame  to  which  the  cylinders  are  secured  that  by 
pressure  on  the  foot  the  flow-  of  gas  may  be  fully  controlled.  This  appli- 
ance is  so  largely  employed  in  England  that  it  forms  a  necessary  part  of 
the  armamentarium  of  every  anesthetist. 

Schleich's  Solution 

The  various  solutions  devised  by  Schleich  are  formulated  on  the  theory 
that  there  is  an  intimate  relation  between  the  boiling  point  of  an  anesthetic 
and  the  extent  of  anesthesia  produced.  He  claims  that  the  lower  the  boil- 
ing point,  the  more  rapid  the  evaporation,  and  that  the  more  rapid  the 
evaporation  of  the  anesthetic,  the  quicker  the  elimination. 

Among  his  solutions,  that  known  as  number  3  is  more  generally  employed 
in  this  country.  The  formula  is  as  follows : 

Chloroform,  chemically  pure,  30  cc. 

Petroleum  ether,  boiling  point  from  60  to  65  c. ,  15  cc. 

Sulphuric  ether,  pure,  80  cc. 

Experiments  have  shown  that  this  solution  is  too  volatile  for  the  Esmarch 
inhaler  or  the  ordinary  ether  cone.  In  its  use  the  anesthetic  should  be 
administered  without  the  removal  of  the  mask  for  the  addition  of  fresh 
solution.  The  mask  should  not  be  pressed  too  closely  to  the  face  for  the 
first  45  to  60  seconds. 


Figure  343.     Esmarch's  Tongue-Holding  Forceps. 

Stone's  Mask,  as  represented  in  figure  341,  is  shaped  like  the  half  of  an 
egg  shell,  its  rim  being  covered  with  a  rubber  circular  cushion  similar  to- 
that  employed  with  Alhs'  ether  inhaler.  This  rim  forms  a  close  jacket 
between  the  mask  and  the  face,  permitting  the  former  to  fit  closely  and 
accurately  at  all  points.  This  cushion  is  inflated  by  means  of  a  special  tube 
and  stop-cock  provided  for  the  purpose.  The  air  required  for  respiration  is 
admitted  through  a  ^-inch  opening  in  the  center  of  the  mask.  This  pat- 
tern is  for  use  in  ordinary  positions.  For  anesthesia  in  Sims'  position  a 
special  inhaler  should  be  provided,  one  in  which  the  opening  is  placed  in 
the  right  side  of  the  mask  instead  of  the  center.  The  inner  portion  of  the 
mask  is  supplied  with  twelve  layers  of  japanned  bibulous  paper,  such  as 
is  used  by  dentists.  This  is  held  in  place  by  two"  spring  wires.  The  latter 
serve  not  only  to  hold  the  paper  in  a  compact  mass,  but  to  prevent  them 
from  resting  against  the  nose.  The  latter  feature  is  necessary  as  the  solu- 
tion is  destructive  to  the  skin  when  long  in  contact  with  it. 

Overholt's  Dropper,  as  exhibited  by  figure  340,  consists  of  a  small  double 
tube  arranged  to  pass  through  an  opening  in  the  cork  of  a  small  bottle. 
The  dropper  is  so  arranged  that  it  may  be  separated  at  a  point  just  above 
the  cork  where  the  tube  is  slightly  bulbous.  If  a  small  quantity  of  cotton 
be  placed  in  the  channel  at  this  point,  a  perfect  working  dropper  will  result, 
the  rapidity  of  the  drops  being  regulated  by  the  quantity  of  cotton  placed 


186 


ANESTHESIA. 


in  the  tube  as  well  as  by  the  position  in  which  the  drop  bottle  is  held.  The 
nearer  the  latter  approaches  the  perpendicular  when  inverted,  the  faster 
the  drops  will  pass  from  the  tube. 

Oxygen  after  Anesthetics  is  recommended  by  many  authors,  particu- 
larly in  England  where  it  has  been  satisfactorily  employed  for  many  years. 
An  outfit,  as  exhibited  in  figure  342,  may  consist  of  a  copper  cylinder  of 
100  gallons'  capacity  provided  with  a  stop-cock,  small  wash  bottle  and  in- 
haling apparatus.  The  latter  is  supplied  with  a  special  inhaler  differing  from 
the  one  shown  in  the  illustration  in  that  it  covers  the  nose  and  mouth,  thus 


Figure  344.    Mathieu's  Tongue-Holding  Forceps. 

securing  to  the  patient  full  inspirations  of  oxygen.  If  preferred,  the  tank 
can  be  supplied  with  a  large  gasometer  by  which  the  amount  of  inhalation 
may  be  carefully  measured. 

Tongue-Holding  Forceps. 

These  are  employed  for  the  purpose  of  drawing  forward  and  firmly  hold- 
ing the  tongue  of  the  patient,  in  order  that  by  falling  backward  it  may  not 
produce  closure  of  the  glottis. 

Esmarch's  Tongue-Holding  Forceps,  as  outlined  in  figure  343,  are  about 
5*^  inches  in  length,  have  scissors  handles,  the  blades  of  which  each  ter- 
minate in  cup-shaped  jaws.  In  other  words,  the  terminations  of  the  jaws  are 
cup  shaped,  with  their  concave  surfaces  facing  each  other.  While  this  for- 
ceps presents  a  small  grasping  or  contact  surface,  its  edges  are  so  carefully 
smoothed  and  rounded  that  laceration  from  its  use  need  not  occur. 


Figure  345.    Houze's  Tongue-Holding  Forceps. 

Mathiue's  Tongue-Holding  Forceps,  as  exhibited  in  figure  344,  consist  of 
a  scissors-handled  instrument  about  7  inches  in  length,  one  jaw  of  which  is 
ring-shaped,  the  fenestra  being  ovoid  and  about  an  inch  in  diameter.  The 
opposite  jaw  is  flat,  with  rounded  borders.  It  is  of  the  same  shape  and  about 
two-thirds  the  size  of  the  fenestra  of  the  other  blade.  The  inner  surfaces  of 
both  jaws  are  covered  with  fine  serrations.  The  tendency  of  this  forceps 
when  applied  is  to  press  the  contact  surface  of  the  tongue  with  the  solid 
jaw  through  the  fenestrated  portion  of  the  opposite  side.  By  means  of  a 
graduated  catch,  any  desired  degree  of  pressure  may  be  obtained.  This 
forceps  affords  a  firm  grip,  and  is  not  often  accidentally  detached. 


MOUTH    GAGS. 


187 


Houze's  Tongue  Holding  Forceps,  as  shown  in  figure  345,  illustrates  a 
light  yet  serviceable  pattern  about  6  inches  in  length,  consisting  of  a 
scissor  shaped  handle,  terminating  in  large  fenestrated  jaws  of  horseshoe 
form.  The  inner  surfaces  of  both  jaws  are  covered  with  fine  serrations,  and 
the  forceps  so  adjusted  that  pressure  is  exerted  upon  an  area  of  more  than 


Figure  346.     Plain  Oral  Screw. 


Figure  347.    Heister's  Gag. 


ordinary  extent.     The  fenestrae  permit  the  bulging  portion  of  the  tongue 
to  partially  escape  through  them,  thus  furnishing  a  firm  grip. 

Mouth  Gags. 

These  consist  of  levers  or  screws  employed  to  forcibly  open  or  hold  the 
jaws  apart.  While  they  are  constructed  of  various  patterns  embracing  many 
mechanical  principles,  they  may  be  divided  into  two  general  classes:  first, 
those  employed  to  force  open  the  mouth  in  cases  of  voluntary  or  involuntary 
fixed  closure;  second,  those  used  to  keep  the  mouth  open  in  operative  cases. 
The  latter  will  be  described  in  the  chapter  devoted  to  oral  surgery. 


Figure  348.    Westmoreland's  Mouth  Gag. 


Figure  349.    Rozier's  Mouth  Gag. 


Forcible  entrance  into  the  mouth  may  usually  be  secured  by  means  of 
screws,  inclined  planes  or  double  levers,  operated  by  screw  power. 

The  Plain  Oral  Screw,  traced  in  figure  346,  is  usually  constructed  of  horn, 
although  bone  and  hard  rubber  have  both  been  employed  for  this  purpose. 
A  flattened  thumb-piece,  which  forms  the  base  of  the  screw,  enables  the 
operator  to  turn  the  instrument  when  in  place.  In  desperate  cases,  when 
ordinary  means  fail  to  secure  an  entrance,  it  has  been  advised  that  a  tooth 
be  broken  that  the  point  of  the  screw  may  be  inserted. 

Heister's  Mouth  Gag,  as  represented  in  figure  347,  consists  of  a  thin, 
separable  wedge  constructed  in  such  a  manner  that  the  two  longitudinal 
portions  of  the  wedge  may  easily  be  separated  by  means  of  a  powerful  screw 


188  ANESTHESIA. 

operated  by  a  thumb-piece.  After  introduction,  the  blades  of  this  instru- 
ment may  easily  be  separated  and  any  amount  of  dilatation  desired  may  be 
produced. 

Westmoreland's  Mouth  Gag,  as  shown  in  figure  348,  consists  of  two  slen- 
der inclined  planes,  resting  with  their  bases  together,  thus  forming  a  wedge. 
Each  face  of  the  wedge  is  sharply  grooved  or  serrated,  so  that  after  being 
forced  between  the  teeth  there  is  comparatively  little  danger  of  its  slipping 
from  place.  The  faces  in  which  the  serrations  are  cut  are  usually  of  lead, 
the  arms  being  manufactured  from  steel.  By  means  of  a  screw  and  thumb- 
piece,  lateral  expansion  of  the  blades  in  any  desired  degree  is  secured. 
Two  upright  posts,  each  attached  to  the  under  blade  and  passing  through 
corresponding  openings  in  the  movable  blade,  insure  the  parallelism  of  the 
blades,  irrespective  of  the  amount  of  separation. 

Rozier's  Mouth  Gag,  as  exhibited  in  figure  349,  consists  of  two  levers 
hinged  together  at  their  fulcra,  spreading  being  secured  by  means  of  a. 
screw  and  thumb-piece.  Like  the  instrument  last  described,  the  faces  of 
the  levers  are  of  lead  and  each  is  in  the  form  of  an  inclined  plane.  This 
instrument  is  intended  more  particularly  for  introduction  in  the  median 
line. 

Sponge  Holders. 

These  are  some  form  of  slender-handled  forceps  employed  as  mopsticks 
for  holding  sponges  while  wiping  away  or  mopping  up  mucus  or  other 
secretions.  As  they  will  be  more  fully  described  under  minor  operative 
surgery,  only  a  single  pattern  suitable  for  use  in  the  mouth  and  throat 
will  be  illustrated  here. 


Figure  350.    Husson's  Aseptible  Sponge  Holder. 

Husson's  Aseptible  Sponge  Holder,  as  traced  in  figure  350,  is  manu- 
factured from  a  single  piece  of  metal,  the  wire  loop  which  constitutes  the 
handle  being  extended  forward  to  form  the  shanks  and  jaws.  A  heavy  metal 
collar  sliding  over  the  blades  compresses  the  self-opening  jaws.  Its  length 
is  about  9  inches. 

LOCAL   ANESTHESIA. 

Local  anesthesia  may  be  produced  by  the  employment  of  cocaine  or  by 
means  of  some  frigorific  process  that  will  benumb  the  parts,  and  con- 
sequently produce  anesthesia  of  greater  or  lesser  degree. 

Cocaine. 

This  agent  serves  to  paralyze  sensory  nerve-endings  whenever  brought 
in  contact  with  them.  It  may  be  administered  by  being  painted  or 
dropped  upon  the  surface,  by  ejection  from  small  canulas  provided  with 
numerous  openings,  or  by  subcutaneous  or  parenchymatous  injections  with 
hypodermic  syringe.  It  does  not  act  readily  upon  or  throiigh  the  skin,  and 
where  this  or  deeper  tissues  require  to  be  anesthetized,  deep  tissue  injections 
should  be  resorted  to.  The  direct  application  of  this  agent  by  brush  or 
other  similar  medium  requires  no  explanation  in  this  chapter.  When. 


LOCAL    ANESTHESIA.  189 

applied  by  means  of  cocaine  canulas,  it  is  necessary  to  attach  the  latter  to 
some  form  of  syringe,  those  of  the  ordinary  hypodermic  variety  being 
usually  preferred. 

Frigorific. 

Partial  or  complete  congelation  of  a  part  may  be  secured  by  the  rapid 
extraction  of  its  natural  heat.  This  condition  may  be  obtained  by  the  ap- 
plication of  agents,  the  exposure  of  which  to  air  causes  sudden  evaporation, 
or  which  extract  heat  by  chemical  action.  Two  processes  are  applicable 
for  this  purpose :  The  ether  spray  and  ethyl  chloride. 

Ether  Spray. 

The  Ether  Spray  consists  of  a  form  of  atomizer  by  means  of  which 
a  vaporized  stream  of  sulphuric  ether  may  be  projected  or  thrown  over 
the  parts  to  be  anesthetized.  For  suitable  patterns  the  reader  is  referred 
to  the  chapter  devoted  to  mouth  and  throat  surgery. 

Ethyl  Chloride. 

This  is  a  colorless  liquid  of  low  specific  gravity,  boiling  at  a  temperature 
of  54°  Fahr.  As  it  boils  at  such  a  low  temperature,  this  liquid  is  almost 


TRUW  GREENE-  CO.          * 


Figure  351.    Small  Glass  Tube  of  Chloride  of  Ethyl. 

constantly  under  pressure,  so  that  it  is  only  necessary  to  release  it  from  its 
container  to  secure  its  expulsion  in  the  form  of  a  spray  or  jet.  When 
properly  projected  against  the  skin  or  mucous  surface,  its  evaporation  is  so 
rapid  as  to  cause  local  refrigeration,  with  consequent  loss  of  nerve  sensa- 
tion. When  stored  in  proper  packages,  its  application  can  be  regulated 
both  as  to  quantity  applied  and  as  to  area  covered.  It  may  be  employed  in 
surgery  in  superficial  cases,  such  as  the  opening  of  abscesses,  enucleation 
of  small  tumors,  operations  on  external  piles,  ingrowing  toe  nails,  the  re- 
duction of  small  dislocations,  etc. 

Usually  anesthesia  may  be  secured  in  from  one-half  to  one  minute,  and 
is  ordinarily  of  about  two  minutes'  duration.  As  found  in  the  market, 
ethyl  chloride  is,  as  a  rule,  contained  in  small  tubes  or  cylinders  constructed 
either  of  glass  or  metal  and  provided  with  screw  caps. 

Chloride  of  Ethyl  may  be  secured  in  glass  tubes,  as  illustrated  in  figure 
351.  Each  of  these  contains  a  sufficient  quantity  of  the  agent  for  from  ten 
to  fifteen  minor  surgical  operations. 


CHAPTER  IX. 


HYPODERMIC  INJECTIONS. 

The  syringe  and  needle  ordinarily  employed  in  making  subcutaneous 
injections  is  popularly  called  a  "hypodermic." 

A  Hypodermic  Syringe,  as  ordinarily  constructed,  consists  of  a  small 
barrel  containing  a  plunger  operated  by  a  suitable  rod  and  handle.  To  the 
opposite  end  of  the  cylinder,  a  needle  is  attached  by  either  a  slip  or  screw 
device.  The  syringe  barrel  may  be  of  any  suitable  material  and  either 
plain  or  graduated.  Many  of  the  piston  rods  are  provided  with  a  screw  stop, 
by  means  of  which  any  given  number  of  minims  may  be  injected.  The 
packing  of  such  pistons  is  usually  of  leather,  although  many  other  sub- 
stances have  been  used  with  varying  success.  While  glass  is  usually  em- 
ployed in  the  construction  of  the  barrels,  brass,  hard  rubber,  silver  and 
various  other  materials  have  been  utilized.  That  these  instruments  have 
been  the  means  of  serious  infections  in  the  past,  there  is  no  question,  for, 
owing  to  their  somewhat  complicated  construction,  it  has  been  almost,  if 
not  quite,  impossible  to  secure  a  serviceable  instrument  that  could  be  surg- 
ically sterilized.  As  stated  in  the  chapter  devoted  to  sterilization,  leather 
packing  will  not  withstand  the  degree  of  heat  necessary  for  disinfecting 
purposes.  Furthermore,  the  metal  caps  upon  most  of  the  glass  cylinders 


Figure  352.    Improved  Leather  Packing  Figure  353.     All  Metal  Hypodermic  Cylinder 

for  Hypodermic  Syringes.  and  Piston. 

are  either  loosened,  or  the  cylinders  will  break  by  expansion  when  sub- 
jected to  this  method  of  disinfection. 

Syringes  constructed  with  metal  barrels  have  not  been  popular  because 
the  surgeon  is  not  able  to  determine  whether  or  not  all  the  previously  con- 
tained air  in  the  cylinder  has  been  expelled. 

Asbestos  fiber  was  for  a  time  advocated  as  a  suitable  material  for  hypo- 
dermic syringe  packing.  Extended  experiments,  however,  revealed  the 
fact  that  the  friability  of  this  substance  rendered  its  use  exceedingly 
dangerous,  as  detached  fragments  were  continually  being  loosened  from 
the  packing  and  either  occluding  the  needle  or  being  injected  subcuta- 
neously.  Koch  thought  to  overcome  all  of  these  difficulties  by  constructing 
a  syringe,  the  expelling  power  of  which  consisted  of  an  ordinary  rubber  bulb 
attached  by  means  of  a  metal  connector  and  stop-cock,  with  a  suitable 
glass  barrel  and  needle.  This  combination  supplied  an  instrument  capable 
of  being  perfectly  disinfected,  but  the  syringe  in  practical  use  does  not 
fulfill  the  requirements. 

The  only  satisfactory  syringes  that  admit  of  easy  and  perfect  steriliza- 
tion are  manufactured  entirely  of  metal  or  glass,  several  patterns  of  which 

190 


HYPODERMIC    SYRINGES. 


191 


can  now  be  obtained  from  surgical  instrument  dealers.  To  Schmidt,  of 
Berlin,  we  believe,  belongs  the  credit  of  having  constructed  the  first  satis- 
factory all-metal  pattern. 

The  syringe  designed  by  this  manufacturer  consisted  of  a  solid  metal 
barrel  containing  a  metallic  plunger  so  constructed  that  it  could  be  expanded 
by  means  of  screw  power,  thus  enabling  the  operator  to  accurately  adjust 
it  to  the  lumen  of  the  tube  and  fill  from  time  to  time  any  space  caused  by 
the  wearing  of  the  parts. 

Syringes  constructed  with  metal  barrels  are  objectionable  only  because 
the  latter  are  not  transparent.  Unquestionably  it  is  a  desirable  feature 
that  the  cylinder  be  manufactured  from  glass  that  the  surgeon  may  deter- 
mine the  character  of  any  fluid  that  may  be  drawn  into  it,  its  quantity,  and 
to  note  whether  or  not  air  be  present  in  the  instrument. 

The  presence  of  air  in  an  all-metal  "hypodermic"  is  not  easily  detected, 


Figure  354.     French  Pattern  Soft  Rubber  Packing.  Figure  355.    Improved  Soft  Rubber  Packing. 

although  with  proper  care  a  surgeon  may  satisfy  himself  beyond  question 
that  nothing  but  the  injecting  fluid  is  contained  in  the  syringe  barrel.  It  is 
only  necessary  to  hold  the  cylinder  with  needle  attached  in  an  upright 
position,  while  slow,  yet  regular  pressure  is  made  on  the  piston  rod.  This 
should  be  continued  until  a  steady  flow  of  liquid  issues  from  the  needle 
point.  If  air  be  present,  bubbles  will  at  first  be  noticed;  as  soon  as  the  air 
is  exhausted,  these  will  be  replaced  by  the  solution  that  will  pass  in  drops 
or  a  steady  stream.  That  the  air  may  be  forced  from  the  needle  as  well  as 
the  syringe  barrel,  the  former  should  be  attached  before  this  test  is  made. 

In  using  a  fine  needle  the  better  plan  is  to  fill  the  syringe  before  attach- 
ing the  needle.  Small  are  preferable  to  large  needles,  because  their  intro- 
duction is  less  painful;  there  is  less  danger  of  injuring  nerves  and  vessels, 
and  less  opportunity  for  the  escape  of  any  injected  fluid  through  the 
needle  wound. 

That  the  laceration  of  tissue  may  be  reduced  to  a  minimum,  none  but 
sharp  needles  should  be  employed.  That  infection  may  not  result  from  a 


Figure  356.    Plain  Hypodermic  Needle. 


JAX  a.  c° 

Figure  357.     Reinforced  Hypodermic  Needle. 


hypodermic  injection,  the  operator  should  see  not  only  that  his  syringe  and 
needle  are  surgically  sterile,  and  the  solution  free  from  bacteria,  but  that 
the  skin  of  the  patient  at  the  point  of  introduction  has  been  previously  well 
cleansed. 

Too  little  attention  has,  we  believe,  been  given  to  the  character  of  the 
injected  solutions.  According  to  Schimmelbusch  a  large  percentage  of 
the  fluid  hypodermic  preparations  carried  in  stock  by  druggists  and  chem- 
ists are  contaminated  by  bacteria.  In  order  to  obviate  this  source  of  infec- 
tion, he  advises  the  use  in  each  case  of  fresh  solutions.  Ordinarily  physi- 
cians are  in  the  habit  of  making  their  preparations  fresh  from  special  tablets 
manufactured  for  hypodermic  purposes.  By  this  method,  while  it  is  con- 
venient and  apparent!}'  practicable,  an  increased  source  of  danger  confronts 
the  operator.  Tablets,  as  a  rule,  are  manufactured  from  unsterilized  drugs, 


192  HYPODERMIC    INJECTIONS. 

in  machines  that  are  never  disinfected  and,  we  believe,  handled  and  packed 
by  employees  \\ho  know  but  little,  if  anything,  of  the  demands  of  asepsis. 
It  is  not  uncommon  for  a  surgeon,  after  carefully  sterilizing  his  hypodermic 
syringe,  to  call  for  a  teaspoon  and  a  little  water  by  means  of  which  he  dis- 
solves a  tablet  in  a  little  liquid,  and  uses  a  container,  all  of  which  are  of 
questionable  sterility.  Too  much  care  can  not  be  exercised  in  the  use  of 
instruments  of  this  class;  particularly  in  intra-articularand  parenchymatous 
injections.  In  these  cases  the  dangers  of  mixed  infection  by  this  source 
should,  as  far  as  possible,  be  avoided. 

In  the  introduction  of  an  ordinary  hypodermic  needle  the  skin  should  be 
grasped  between  the  thumb  and  finger  of  the  free  hand,  slightly  raised  from 
the  muscular  sheath  and  closely  pressed  or  pinched  in  order  to  partially 
paralyze  the  smaller  nerves.  After  the  point  of  the  needle  has  been  forced 
through  the  skin,  it  is  well  to  move  the  skin  and  needle  slightly  to  one  side 
before  further  penetration,  in  order  that  when  the  parts  resume  their 
normal  position,  the  opening  may  not  be  a  continuous  one.  Sacs  and  other 


THUAX5CD, 

Figure  358.    Aspirating  Hypodermic  Needle. 

•cavity  walls  should  be  punctured  obliquely  that  the  opening  may  be  more 
readily  closed  by  natural  means  after  the  withdrawal  of  the  needle. 

In  the  operating-room  several  hypodermic  syringes  should  be  in  good 
working  order,  at  least  two  of  which  should  be  sterile  and  ready  for  use. 

•The  needles  are  best  sterilized  by  boiling  in  soda  solution.  If  made 
from  platinum,  they  may  be  disinfected  by  heating  in  a  spirit  lamp,  or 
similar  flame.  When  not  in  use,  a  silver  wire  should  be  kept  within  the 
needle  as  it  is  less  liable  to  corrode. 

The  use  of  a  piston  usually  necessitates  the  application  of  a  lubricant  in 
order  that  the  space  between  it  and  the  cylinder  may  be  filled  so  closely  that 
no  air  can  pass  during  the  backward  or  forward  motion  of  the  plunger. 
While  oil  has  been  commonly  used  for  this  purpose,  we  recommend  steril- 
ized glycerine  as  being  preferable. 

After  use,  a  hypodermic  syringe  should  be  carefully  cleansed  and  steril- 
ized, so  that  it  may  not  become  a  breeding  ground  for  bacteria. 

Instruments  of  this  class  should  be  so  constructed  that  they  may  be  used 
for  aspirating,  thus  answering  a  two-fold  purpose,  although  it  is  preferable 


Figure  359.     Hypodermic  Trocar. 


for  the  surgeon  to  keep  a  special  syringe  to  be  used  exclusively  for  this 
purpose,  in  order  that  the  dangers  of  infection  be  decreased. 

Syringes  of  improved  design  are  now  constructed  with  a  removable  sec- 
tion or  cap  at  the  distal  end  of  the  barrel.  This  cap  includes  the  head  to 
which  the  needle  is  attached.  After  the  removal  of  this  section,  the  operator 
drops  the  tablet  into  the  syringe  barrel  where  it  may  be  readily  dissolved  in 
water.  This  improvement  does  not  necessitate  the  use  of  a  separate  vessel 
for  the  solution,  and  thus  one  danger  of  infection  is  removed. 

Many  "hypodermics"  are  constructed  with  finger  rings,  or  projecting 
arms  by  which  a  compensating  grip  may  be  obtained  on  the  syringe  barrel. 

If  the  latter  be  tightly  packed,  considerable  force  may  be  necessary  to 


HYPODERMIC    SYRINGES. 


193 


operate  the  piston.  By  grasping  the  finger  rings  or  arms  with  the  first  and 
second  fingers,  the  pressure  force  exerted  on  the  plunger  may  be  counter- 
balanced and  no  movement  of  the  needle  in  the  tissues  need  occur. 
Syringes  not  provided  with  these  adjustments  frequently  cause  unnecessary 
parn,  even  in  the  hands  of  the  most  careful  operators. 

"Hypodermics"  vary  in  size  from  those  holding  but  10  or  15  drops  to 
those  with  a  capacity  of  i  to  4  ounces.  Those  of  extra  large  size  are 
occasionally  employed  for  parenchymatous  infusions  or  the  injections  of 
alcoholic  stimulants.  Medium-sized  instruments  are  those  holding  from 
2  to  4  drachms.  They  are  used  for  the  injection  of  antitoxins  and  the 
various  other  remedies  employed  in  serum  therapy. 

In  selecting  a  syringe  the  purchaser  is  too  frequently  influenced  by  the 
style  and  character  of  the  case  in  which  the  apparatus  is  to  be  carried.  An 
instrument  of  inferior  make,  placed  in  an  attractive  container,  particularly 
of  some  new  pattern,  will  often  find  a  ready  sale  where  one  of  perfect  con- 
struction, but  in  an  ordinary  case  would  hardly  find  a  buyer. 

The  customer  in  making  a  selection  should  choose  a  pattern  capable  of 
thorough  sterilization,  free  from  complications,  of  good  workmanship,  with 


Figure  360.    Hypodermic  Syringe  in  Ordinary 
Case,  with  Bottles  for  Tablets. 


Figure  361.     Hypodermic  Syringe 
in  Flexible  Case. 


all  parts  accessible,  and  a  cylindrical  lumen  that  presents  to  the  piston  pack- 
ing an  equal  pressure  at  every  point  in  its  length. 

The  author  has  frequently  noted  cases  where  surgeons  have  objected  to 
a  hypodermic  syringe  because  they  found  that  after  placing  the  tip  of  the 
finger  over  the  needle  opening  and  withdrawing  the  piston,  the  latter 
would  fail  to  plunge  forward  and  fill  the  vacuum  caused  by  the  withdrawal. 
This  is  not  a  scientific  test,  for  such  an  execution  must  depend  entirely  on 
the  amount  of  pressure  exerted  by  the  packing  on  the  inner  walls  of  the 
cylinder.  In  instruments  of  modern  make  where  the  diameter  of  the  pack- 
ing is  enlarged  or  decreased  by  screw  power,  an  imperfect  syringe  if 
loosely  packed  and  well  lubricated,  would  quickly  respond  to  such  a  test, 
while  one  with  perfect  barrel  and  improved  packing  if  expanded  sufficiently 
to  tightly  fill  the  cylinder  would  exert  a  lateral  pressure  adequate  to  over- 
come the  atmospheric  force  produced  by  the  vacuum.  The  test,  therefore, 
as  usually  applied,  is  worthless. 

As  formerly  manufactured,  the  pistons  of  "hypodermics"  differed  little, 
if  any,  from  those  found  in  the  plain,  hard  rubber  syringes  of  the  market. 
The  demands  for  a  packing  that  would  remain  moist,  that  the  syringe  at 

13 


194 


HYPODERMIC    INJECTIONS. 


all  times  might  be  in  readiness  for  use,  resulted  in  the  construction  of 
several  improved  forms,  particularly  adapted  to  accomplish  this  result. 
The  illustration  shown  in  figure  352  represents  one  of  the  best  of  these 
patterns. 

It  consists  of  two  hemispherical  leather  packings  with  the  curved  sur- 
faces opposed  to  each  other,  and  so  adjusted  as  to  leave  a  circular  grooved 
space  between  them  which  serves  to  retain  a  quantity  of  lubricating  fluid. 
This  space  consists  of  a  deep  trough  cut  in  the  periphery  of  a  metal  disc. 
Syringes  thus  constructed  require  "oiling"  only  occasionally,  excepting 
that  the  lubricant  will  need  to  be  renewed  after  each  sterilization. 

An  All  Metallic  Cylinder  and  Piston  is  represented  in  figure  353,  the 
lumen  of  the  former  being  carefully  bored  to  insure  accurac)T.  The  plunger 
consists  of  a  thin  ring  of  expansible  metal  surrounding  a  solid  cone-shaped 
head.  The  interior  arrangement  is  such  that  the  movement  of  the  cone- 


Figure  362.    Hypodermic  Syringe  in 
Upright  Metal  Case. 


Figure  303.    Walcher's  Hypodermic  Syringe. 


shaped  head  is  controlled  by  a  threaded  device,  and  so  adjusted  that  by 
turning  a  screw,  the  cone  may  be  drawn  into  the  ring  or  chamber,  where, 
by  pressure  from  within  outward,  lateral  expansion  is  produced. 

While  the  amount  of  this  enlargement  is  not  great,  it  is  sufficient  to  fill 
any  space  that  may  be  caused  by  the  wearing  away  of  the  cylinder.  As 
the  instrument  is  manufactured  from  brass,  nickeline  or  German  silver, 
it  will  not  rust  and  may  be  easily  sterilized  by  any  thermal  method. 

Hypodermic  Pistons  with  soft  rubber  packing  are,  we  believe,  of  French 
origin.  As  first  constructed,  they  consisted  of  two  soft  rubber  hemi- 
spherical discs,  arranged  with  their  convex  surfaces  each  facing  the  other. 
Upon  the  outer  face  of  each  of  the  two  pieces  of  rubber,  a  metal  collar  was 
placed,  the  piston  rod  passing  through  the  four  pieces  and  so  adjusted  by 
screw  device  that  the  distance  between  the  two  metal  plates  could  be 
lessened  or  increased  as  desired.  The  drawing  together  of  the  two 
metal  discs  imparted  an  outward  pressure  upon  the  rubber  hemispheres, 


HYPODERMIC    NEEDLES    AND    TROCARS. 


195 


causing  lateral  expansion  and  producing  a  greater  pressure  upon  the  lumen 
of  the  cylinder.  This  form  of  packing  is  shown  in  figure  354. 

The  disadvantage  in  this  pattern  was  due  to  the  fact  that  where  an  extra 
amount  of  piston  pressure  was  desired,  particularly  after  the  syringe  had 
been  in  service  for  some  time,  there  was  a  tendency  on  the  part  of  the 
rubber  hemisphere  to  evert  or  turn  backward,  thus  permitting  the  passage 
of  air. 

The  illustration  sketched  in  figure  355  represents  a  soft  rubber  packing 
of  a  design  not  open  to  this  objection.  It  consists  of  a  single  disc,  the  latter 
shaped  as  though  cut  from  a  section  of  a  cone.  This  is  held  in  place  by 


Figure  364.    Luer's  Hypodermic  Syringe. 

metal  collars,  one  on  each  side,  one  playing  loose  upon  the  piston  shaft,  the 
other  operated  by  a  screw. 

In  molding  the  rubber  disc,  a  cone-shaped  depression  is  formed  in  the 
center  of  its  base.  That  side  of  the  outer  metal  collar  in  contact  with  this 
rubber  disc  is  provided  with  a  cone-shaped  extension  that  fits  into  the  recess 
above  referred  to.  By  turning  the  piston  rod  to  the  right  or  left,  lateral 
expansion  of  the  rubber  disc  may  be  secured  and  any  degree  of  pressure  by 
the  piston  on  the  lumen  of  the  cylinder  obtained. 

Hypodermic  Needles  and  Trocars 

These  may  be  procured  of  any  desired  caliber  or  length ;  extra  fine  ones 
being  usually  preferred.  They  should  be  manufactured  from  that  quality 


Figure  365.    Detmer-Robinson's  Hypodermic  Syringe. 

of  tubing  known  as  seamless,  that  they  may  not  only  be  perfectly  smooth, 
but  that  no  leakage  may  occur  throughout  the  length  of  the  needle. 

Usually  they  are  attached  to  the  syringes  by  a  screw  or  slip  joint.  The 
former  plan  furnishes  a  joint  more  fixed  and  stable  than  the  latter,  but 
possesses  the  disadvantage  of  requiring  a  washer  that  the  union  of  the  two 
parts  may  form  an  air-tight  joint.  A  needle  constructed  with  a  slip  joint  if 
tightly  pressed  into  position  with  a  rotary  motion,  will  remain  sufficiently 
secure  for  injecting  purposes.  This  pattern,  however,  requires  a  syringe 
tip  and  a  needle  socket,  both  of  which  must  be  absolutely  true  or  else  a 
leaky  joint  will  result. 


196 


HYPODERMIC  INJECTIONS. 


Various  materials  have  been  utilized  in  the  manufacture  of  needles  for 
hypodermic  purposes,  but  we  believe  that  all  have  been  practically  aban- 
doned with  the  exception  of  steel  and  platinum.  The  former  supplies  a 
needle  of  good  quality,  of  moderate  price  and  one  that  may  be  sharpened 
to  a  cutting  edge,  which  it  will  retain  for  a  considerble  length  of  time.  Its 
disadvantage  is  the  readiness  with  which  the  lumen  of  the  tube  becomes 
rusted  and  thus  occluded.  Unless  careful  precautions  be  taken  after  each 
injection,  steel  needles  soon  become  unfit  for  use.-  After  an  application 
they  should  not  only  be  thoroughly  dried,  but  the  lumen  of  the  tube 
should  be  traversed  with  a  stylet  in  the  form  of  a  slender  wire  and  a  sec- 
tion of  the  latter  should  be  permitted  to  remain  within  the  needle  until 
again  wanted  for  use.  On  account  of  the  readiness  with  which  an  iron  wire 
will  rust,  silver  will  be  found  preferable,  and  it  will  be  better  if  the  diameter 
of  the  wire  be  somewhat  smaller  than  the  tube  lumen. 

The  Hypodermic  Needle,  traced  in  figure  356,  is  of  the  ordinary  type, 
while  figure  357  exhibits  a  pattern  known  as ' '  reinforced. ' '  Reinforcement  is 
often  employed  in  the  construction  of  extra  fine  needles  to  strengthen  them 
that  they  may  not  break  or  become  bent  when  forced  into  the  tissues.  The 
reinforcement  consists  of  an  additional  piece  of  larger  tubing  surrounding 
the  inner  canula  and  extending  about  one  half  of  its  length.  After  being 
forced  into  place,  the  two  are  brazed  together. 


Figure  366.    Ferguson's  Hypodermic  Syringe. 

The  Aspirating  Hypodermic  Needle,  exhibited  in  figure  358,  is  a  long  needle 
of  large  caliber,  similar  to  those  in  use  with  aspirators ;  they  may  be  pro- 
cured of  any  size  or  length. 

The  Hypodermic  Trocar  and  Canula,  illustrated  in  figure  359,  may  be 
arranged  with  either  a  screw  or  slip  joint  for  attachment  to  the  syringe. 
While  they  may  be  manufactured  of  any  size,  they  are  usually  about  number 
6  French  scale. 

Hypodermic  Syringes. 

As  generally  understood,  these  include  two  or  more  needles,  the  whole 
included  in  some  form  of  a  case. 

The  Hypodermic  Syringe,  portrayed  in  figure  360,  exhibits  one  of  the 
best  known  forms  of  cases  in  common  use.  Originally  each  box  included  a 
slender  glass  vial  in  which  to  store  and  transport  a  morphine  solution. 
Since  the  introduction  of  tablets,  this  space  has  been  utilized  for  carrying 
small  bottles  of  hypodermic  tablets.  The  case  is  leather-covered  and 
usually  of  cheap  construction.  Underneath  the  cover  a  flap  is  often  placed, 
beneath  which  extra  wires  for  use  in  the  needles  and  some  additional 
washers  may  be  carried. 


HYPODERMIC    SYRINGES. 


197 


The  Hypodermic  Syringe,  illustrated  in  figure  361,  was  designed  by  the 
author  many  years  ago.  It  was  sought  to  improve  upon  the  design  before 
described  by  the  construction  of  an  all  leather  pattern,  manufactured  from 
material  that  would  supply  a  soft  and  flexible  case  which  might  be  carried  in 
the  pocket  with  as  little  inconvenience  as  an  ordinary  pocket-book.  Like 
the  case  above  referred  to,  it  originally  contained  bottles  for  fluids;  these 
are  now  utilized  for  hypodermic  tablets.  The  apparatus  is  so  small  that 
it  may  be  easily  carried  in  the  vest  pocket. 

The  Hypodermic  Syringe  in  upright  metal  case,  delineated  in  figure  362, 
is  one  of  the  most  popular  forms  of  cases  in  the  market  at  this  writing.  It 
is  of  similar  construction  to  the  match-safe  that  has  been  in  common  use  for 
many  years.  The  top  of  the  main  chamber  is  covered  with  a  metal  plate  sup- 
plied with  perforations  to  admit  the  various  articles  contained  in  the  case. 
The  syringe  passes  through  and  rests  in  the  larger  of  these  openings.  The  four 


Figure  367.     Large  Hypodermic  Syringe  with  Stop-cock. 

next  in  size  each  contains  a  small  vial  in  which  may  be  placed  "hypodermic 
tablets.  The  two  remaining  openings  supply  a  secure  resting-place  for  the 
needles.  In  some  patterns  a  thread  is  cut  in  the  needle  openings  and  a 
screw  provided  on  the  outer  surface  of  the  needle  head  that  the  needles 
may  be  securely  held  and  danger  of  injury  to  the  points  avoided. 

Walcher's  Hypodermic  Syringe,  as  evidenced  in  figure  363,  is  one  of  the 
best  of  the  German  designs. 

In  the  manufacture  of  this  syringe  no  effort  has  been  made  to  construct 
an  adjustable  piston.  The  cylinder  is  of  glass,  while  the  piston  is  a  solid  rod 
of  metal  fitting  closely  in  the  lumen  of  the  cylinder  and  extending  its  full 
length:  By  employing  glycerine  or  any  other  heavy  lubricant  this  arrange- 
ment will  produce  an  air-tight  joint.  The  metal  tips  attached  at  each  end 
of  the  glass  cylinder  are  arranged  with  screw  adjustment.  The  needle- 
heads  instead  of  slipping  over  as  in  ordinary  patterns,  slip  in  and  are  cone- 
shaped,  the  opening  that  receives  them  being  sufficiently  large  for  the  in- 
troduction of  a  tablet.  The  syringe  as  usually  found  in  the  market  is 
graduated  on  the  barrel  with  plain  black  letters,  is  of  15  minim  capacity, 
has  two  needles  and  is  contained  in  a  small  metal  case  neatly  arranged. 


198 


HYPODERMIC    INJECTIONS. 


Luer's  Hypodermic  Syringe,  as  depicted  in  figure  364,  is  one  of  the  best 
of  the  French  patterns. 

The  barrel  and  piston  are  of  glass,  the  latter  without  valve  or  packing. 
The  cylinder  is  accurately  ground  to  fit  the  chamber  and  is  so  carefully 
adjusted  that  it  forms  an  air-tight  joint.  The  outer  end  of  the  syringe 
barrel  is  constructed  to  form  a  slip  joint  with  needles  of  ordinary  pattern. 

Many  manufacturers  have  failed  in  their  attempts  to  construct  a  satis- 
factory syringe  of  this  pattern.  Luer  of  Paris  is,  we  believe,  the  first  if  not 
the  only  one  who  has  successfully  accomplished  the  feat.  What  appears  to 
be  a  simple  mechanical  proposition,  in  execution  proves  a  difficult  under- 
taking. The  instrument  has  a  transparent  barrel  and  may  be  easily 
cleansed  and  sterilized.  The  only  objections  to  it  are  its  high  price  and 
liability  to  breakage.  As  ordinarily  supplied,  it  may  be  procured  with  two 
needles  and  six  or  more  tablet  bottles,  all  contained  in  an  aluminum  case, 
curved  to  the  arc  of  a  circle  that  it  may  fit  the  body  when  the  instrument  is 
carried  in  the  vest  pocket. 

Detmer-Robinson's  Hypodermic  Syringe,  as  shown  in  figure  365,  con- 
sists of  a  tube  of  brass  with  solid  brass  plunger,  the  latter  so  accurately 
constructed  as  to  form  a  perfect  joint.  The  needles  accompanying  this 


Figure  368.    Antitoxine  Syringe. 

appliance  are  of  the  slip  pattern,  and  as  there  is  no  constriction  in  the  barrel, 
they  are  manufactured  with  a  base  the  size  of  the  piston,  so  that  they  slip 
into  instead  of  over  the  barrel  tip.  This  furnishes  an  instrument  easily 
sterilized,  the  only  objection  being  the  non- transparency  of  the  cylinder. 
As  usually  placed  upon  the  market,  it  is  contained  in  a  small  flexible  leather 
case  with  four  needles.  Its  extreme  measurements  are  i  yz  inches  in  width, 
3j^  inches  in  length  and  ^  inch  in  thickness. 

Ferguson's  Hypodermic  Syringe,  as  pictured  in  figure  366,  furnishes  one 
of  the  most  compact  syringes  that  has  been  brought  to  our  notice.  It  is 
manufactured  entirely  of  metal  and  is  so  adjusted  that  it  requires  no  pack- 
ing. The  plunger  is  constructed  on  the  plan  shown  by  figure  353,  and  is  so 
arranged  that  any  degree  of  lateral  pressure  on  the  lumen  of  the  cylinder 
may  be  obtained. 

The  needles  are  of  the  pattern  known  as  the  slip  joint,  and  each  socket 
is  accurately  ground  to  fit  the  syringe  tip.  The  piston  rod  is  hollow  and  is 
utilized  as  a  container  for  the  needles  and  trocar.  The  piston  shaft  is 
graduated  in  both  drachms  and  cubic  centimeters. 

The  proximal  end  of  the  cylinder  is  provided  with  a  flange  of  sufficient 
width  to  afford  a  firm  compensating  grip  when  the  syringe  is  in  operation. 
While  this  syringe  was  designed  particularly  for  intra-articular  injections, 


ANTITOXINE    SYRINGES.  199 

it  may  be  used  for  explorative  purposes  and  for  such  procedures  is  con- 
structed with  a  trocar  that  may  be  attached  to  the  syringe  in  the  same 
manner  as  an  ordinary  needle.  This  trocar  may  be  used  independently  of 
the  syringe. 

The  usual  capacity  is  8  drachms.  Smaller  sizes  of  2  and  4  drachm 
capacity,  for  parenchymatous  injections,  such  as  the  introduction  of 
antitoxine  and  similar  preparations  can  also  be  obtained. 

The  Large  Hypodermic  Syringe  with  stop-cock,  exhibited  by  figure  367, 
consists  of  a  syringe  barrel  of  ^  ounce  capacity,  provided  with  metal  rings 
by  means  of  which  the  plunger  may  be  easily  operated.  Its  particular 
feature  consists  of  a  small  stop-cock  that  may  be  introduced  between  the 
syringe  barrel  and  the  needle.  This  is  intended  particularly  for  aspirating 
purposes,  and  it  furnishes  means  for  emptying  the  syringe  barrel  of  its 
aspirated  contents  without  removing  the  needle  from  the  tissue,  or  discon- 
nection. When  the  handle  of  the  stop-cock  is  on  a  line  with  the  needle  and 
syringe,  the  opening  is  continuous.  If  the  handle  be  turned  at  right  angles, 
connection  between  the  syringe  and  needle  is  broken  so  that  fluid  may 
be  drawn  into  the  barrel  or  ejected  therefrom  by  means  of  a  side  opening. 
Usually  this  instrument  can  be  purchased  with  three  needles,  one  of  which 
is  of  large  size  and  extra  length,  and  an  aspirating  trocar. 

The  Antitoxine  Syringe,  traced  in  figure  368,  exhibits  an  improved  form 
for  use  in  cases  where  it  is  necessary  to  inject  ^  an  ounce  or  more  of  fluid. 
The  packing  is  of  the  soft  rubber  type  as  shown  by  figure  354.  The  syringe 


Figure  369.    Koch's  Hypodermic  Syringe. 

here  shown  is  of  i  ounce  capacity  and  so  constructed  as  to  furnish  a  firm 
grip.  In  order,  however,  that  unnecessary  pressure  may  not  be  brought 
upon  the  needle  after  insertion,  the  connection  of  the  needle  with  the  syringe 
barrel  is  made  by  means  of  a  short  piece  of  soft  rubber  tubing  about  one 
inch  in  length.  This  attachment  enables  the  operator  to  move  the  syringe 
barrel  without  changing  the  position  of  the  needle.  The  needles  are  two 
in  number,  both  of  large  size  and  reinforced  as  exhibited  by  figure  357. 
All  the  joints  are  secured  by  rubber  packing,  and  the  whole  apparatus, 
including  the  case,  may  be  easily  sterilized. 

Koch's  Hypodermic  Syringe,  described  in  figure  369,  as  previously 
mentioned,  was  devised  with  a  view  of  meeting  all  the  requirements 
demanded  by  a  perfect  instrument.  It  is  operated  by  the  expanding  and 
collapsing  of  a  soft  rubber  bulb,  the  former  filling  the  syringe,  the  latter 
expelling  its  contents.  The  needle  is  attached  to  a  glass  barrel  by  a  slip 
joint,  the  glass  being  accurately  ground  to  fit  the  needle  socket  that  air  may 
not  pass  through  the  junction  of  the  metal  and  the  glass.  The  glass  barrel 
is  attached  to  the  metal  connector  or  stop-cock  by  means  of  a  screw  joint 
and,  as  the  bulb  can  be  removed  from  this  connector,  the  syringe  is  separable 
into  various  parts  to  permit  of  thorough  cleansing  and  sterilization. 


200 


HYPODERMIC    INJECTIONS. 


This  syringe  in  practical  use  has  failed  to  fill  the  indications  at  first 
anticipated.  It  possesses  too  little  force  and  usually  can  not  be  employed  for 
the  injection  of  remedies  of  a  thick  or  oily  nature.  If  the  bulb,  when  com- 
pressed, fails  to  eject  the  syringe  contents,  it  can  be  refilled  only  with  great 
difficulty  unless  the  needle  is  withdrawn.  More  important  than  this,  how- 
ever, is  the  fact  that  the  instrument  can  not  be  used  as  an  aspirator  or  ex- 
ploring syringe. 


Figure  370.    Thomas'  Hypodermic  Syringe. 

Thomas'  Hypodermic  Syringe,  as  shown  in  figure  370,  consists  of  a  heavy 
rubber  bulb  supplied  with  a  needle  and  hard  rubber  connector.  The 
instrument  is  constructed  on  the  plan  of  Koch's,  but  without  the  stop-cock 
noticeable  in  the  latter.  The  bulb  may  be  of  any  capacity,  those  of  one  or 
two  drachms'  capacity  being  preferred  usually.  If  they  be  of  heavy 
material,  the  expansive  force  will  enable  the  operator  to  easily  fill  the 
syringe  with  fluid.  The  presence  of  air  may  be  detected  in  the  same  man- 
ner as  in  an  ordinary  syringe.  The  instruments  are  easily  cleansed  and 
purchasable  at  a  low  price. 


CHAPTER  X. 


PARACENTESIS. 

This  is  employed  to  evacuate  collections  of  fluids  generally  or  as  a 
means  of  securing  samples  of  suspected  fluids  for  examination. 

In  order  to  reduce  the  dangers  of  primary  and  mixed  infection  to  a 
minimum,  the  surgeon  should  make  preparations  as  for  an  aseptic  opera- 
tion. 

If  the  trocar  or  needle  be  large,  an  incision  through  the  overlying  skin 
may  be  made  with  a  scalpel  or  sharp-pointed  bistoury. 

Complete  anesthesia  is  seldom  necessary.  Local  anesthesia  is  frequently 
demanded,  and  for  this  purpose  ether  spray  or  chloride  of  ethyl  may  be  em- 
ployed. In  the  absence  of  these,  the  application  of  ice  or  ice  and  salt  will 
produce  a  benumbing  effect  that  will  answer  a  very  good  purpose. 

After  the  final  withdrawal  of  the  instrument,  the  puncture  should  be 
closed  by  firm  pressure  of  the  thumb  or  finger,  and  the  site  of  operation 
covered  with  an  antiseptic  absorbent  dressing,  secured  by  a  bandage  or 
plaster. 

The  operation  may  consist  of  aspiration  or  tapping  with  trocar  or  needle. 


ASPIRATION. 

This  is  employed  to  forcibly  evacuate  encysted  or  retained  fluids  from 
cavities  without  the  introduction  of  air.  The  instrument  utilized  for  this 
purpose  is  called  an  aspirator.  The  force  employed  is  atmospheric  pressure 
in  vacuum  form,  assisted  in  some  cases  by  the  nature  contractile  power  of 
the  inclosing  wall. 

Such  instruments  usually  consist  of  a  sharp-pointed  hollow  needle  or 
canula  having  an  opening  in  its  distal  extremity,  the  proximal  end  being 
attached  to  a  rubber  tube  connecting  with  a  vacuum  chamber.  The  vacuum 
producing  force  may  be  that  of  a  piston  pump,  rubber  tube  compression, 
collapsable  rubber  bag,  or  an  ordinary  siphon. 

Piston  Pump  Aspirator. 

A'urious  patterns  of  aspirators  designed  to  be  operated  by  some  form  of 
piston  pump  have  been  manufactured  for  many  years.  Prominent  among 
these  designs  are  Potain's,  Dieulafoy's,  Peaslee's,  etc.  The  latter  is  con- 
structed with  a  plain  piston  to  which  is  attached  a  two-way  stop-cock  by 
which  the  aspirating  fluid  drawn  into  the  cylinder  may,  after  turning  the 
stop-cock,  be  ejected  through  a  side  opening. 

The  Dieulafoy  Aspirator  differs  from  the  above  in  possessing  a  large 
cylinder,  the  piston  of  which  is  operated  by  screw  power.  Since  the 

201 

COLLlEtilE   LM 


202 


PARACENTESIS. 


principles  of  asepsis  have  been  generally  accepted  and  the  dangers  of 
primary  and  mixed  infections  known,  both  of  these  instruments  have 
practically  passed  out  of  use,  so  much  so  that  in  a  short  time  we  predict 
they  will  be  known  only  in  history.  For  this  reason  a  more  minute  descrip- 
tion will  not  be  attempted  here. 

Potain's  Aspirator,  as  displayed  in  figure  371,  exhibits  an  improved  form 
of  aspirator  now  in  general  use.  It  consists  of  a  carefully  constructed  piston 
pump,  terminating  in  a  "T"  shaped  head,  supplied  with  two  automatic 
metal  valves,  one  the  reverse  of  the  other.  These  valves  are  so  constructed 
that  while  one  admits  fluid  to  the  cylinder,  the  other  will  only  permit  of  its 
escape.  To  the  first  of  these  a  rubber  hose  is  attached  that  connects  with  a 
two-way  tube  passing  through  a  cork,  the  latter  placed  in  a  bottle  of  any 
suitable  size.  Each  of  the  two  tubes  .passing  through  this  cork  is  supplied 
with  a  stop-cock  by  which  the  flow  of  fluid  either  to  or  from  the  bottle 
may  be  regulated.  To  the  second  of  these  tubes  a  rubber  hose  is  attached, 
its  distal  end  terminating  in  an  aspirating  needle  or  trocar.  By  closing  the 
stop-cock  connected  with  the  latter  and  opening  the  one  first  referred  to, 
when  the  pump  is  placed  in  operation  a  vacuum  may  be  produced  in  the 
bottle.  If  the  stop-cock  leading  from  the  pump  be  then  closed,  the  needle 
inserted  in  the  cavity  to  be  drained,  and  the  stop-cock  leading  from  it  to 


Figure  371.    Potain's  Aspirator. 

the  bottle  be  opened,  the  aspirating  power  will  be  placed  in  action  at  once 
and  the  fluid,  if  any,  will  be  drained  and  deposited  in  the  bottle.  The 
vacuum  force  may  be  continued  by  opening  the  small  stop-cock  leading  to 
the  pump  and  the  latter  kept  in  action  during  the  aspirating  of  the  cavity. 
It  will  thus  be  seen  that  as  the  aspirating  fluid  passes  only  through  the 
needle,  rubber  hose  and  one  of  the  metal  tubes  in  the  cork,  the  pump  and 
its  connecting  tubes  are  in  no  danger  of  direct  infection.  For  this  reason 
and  because  the  air  pressure  may  be  maintained  continuously  and  uni- 
formly, this  instrument  has  replaced  those  formerly  in  use. 

This  aspirator  may  be  converted  into  an  injector  by  attaching  a  piece  of 
rubber  hose  that  will  extend  from  the  bottom  of  the  bo'ttle  and  connect  with 
the  lower  end  of  the  metal  tube  leading  to  the  aspirating  needle.  By  plac- 
ing the  fluid  to  be  injected  in  the  bottle  and  reversing  the  action  of  the 
pump  so  that  it  will  force  air  into  the  bottle,  a  sufficient  pressure  may  be 
exerted  to  cause  a  flow  of  the  fluid  into  the  cavity.  This  may  be  with- 
drawn by  changing  the  instrument  to  an  aspirator  as  before  described. 


ASPIRATION. 


203 


Compressible  Rubber  Tube  Aspirator. 

The  Author's  Surgical  Pump,  as  pictured  in  figure  372,  is  an  appliance 
that  may  be  used  either  as  a  force  or  vacuum  pump,  depending  only  on  the 
direction  in  which  the  crank  is  turned.  It  consists  of  a  horse-shoe  shaped 
frame,  on  the  inner  surface  of  which  is  clamped  a  piece  of  rubber  hose  so 
adjusted  as  to  describe  the  form  of  the  letter  "U."  Passing  through  the 
case  is  a  shaft  moved  by  a  suitable  crank,  to  which  is  attached  a  rotat- 
ing arbor  carrying  two  rollers.  These  rollers  .are  connected  through  the 
center  of  the  arbor  by  a  double-threaded  rod,  moved  by  a  milled-edged 
wheel.  By  turning  this  small  wheel  any  degree  of  pressure  desired  can  be 
produced  upon  the  rubber  hose.  With  proper  adjustment,  each  revolution 
of  the  crank  will  displace  twice  as  much  fluid  as  is  contained  in  that  portion 


Figure  372.    Author's  Surgical  Pump.    (The  Improved  Allen.) 

of  the  rubber  tubing  forming  the  half  loop.  As  the  rollers  in  passing 
around  the  circle  rest  continuously  on  the  tubing  completely  closing  it  at 
some  point,  there  is  no  necessity  for  valves. 

To  utilize  the  pump  as  an  aspirator,  it  is  only  necessary  to  connect  the 
rubber  tubing  with  the  piece  of  small  glass  tubing,  two-way  stop-cock,  and 
the  trocar  shown  in  figure  373,  and  attach  them  to  the  pump. 

The  aspirators  heretofore  in  the  market  have  either  necessitated  the  use 
of  a  vacuum  bottle,  or  required  the  turning  of  a  stop-cock  every  time  the 
cylinder  was  filled.  The  latter  work  slowly,  have  valves  that  are  easily 
clogged,  and  are  frequently  unsatisfactory.  The  former  require  the  empty- 
ing of  the  bottle  every  time  it  is  filled  and  the  creating  of  a  new  vacuum, 
and,  as  they  will  not  operate  at  all  without  a  vacuum,  they  require  an  air 
pump  always  in  perfect  working  order.  As  this  surgical  pump  possesses  no 
piston  valves  or  stop  cocks,  and  as  it  is  used  without  a  vacuum  bottle,  the 


204  PARACENTESIS. 

time  usually  employed  in  producing  a  vacuum  and  in  emptying  the  bottle 
is  saved.  Its  advantages  as  an  aspirator  are : 

Its  great  power  permits  the  operator  to  employ  a  small  needle. 

Its  reversible  current  enables  him,  if  the  needle  becomes  clogged,  to 
reverse  its  action,  and  force  out  the  occluding  substance. 

There  is  no  loss  of  time  in  operating  it,  as  there  is  no  vacuum  bottle  to 
be  exhausted.  Vacuum  force  is  exerted  as  soon  as  the  crank  is  turned,  and 
continues  without  interruption. 

The  amount  of  power  exerted  is  or  may  be  uniform,  is  constantly  under 
the  control  of  the  operator,  and  may  be  little  or  great  as  desired.  In  using 
an  ordinary  aspirator,  as  fast  as  the  bottle  fills  the  power  decreases,  and 
when  full,  the  pump  must  be  disconnected,  the  bottle  emptied  and  a  new 
vacuum  created. 

If  the  operator  desires  to  inject  and  wash  out  the  cavity,  he  has  but  to 
turn  the  stop-cock  and  close  the  opening  to  the  needle.  The  free  end  of 
the  tube  may  then  be  placed  in  the  fluid  to  be  injected,  and  the  current 
reversed.  This  will  force  the  air  out  at  the  side  opening  of  the  stop-cock 
and  permit  the  cleansing  of  the  tube.  If  a  quantity  of  the  fluid  be  forced 
through  this  opening,  and  the  current  continued  until  it  passes  freely  and 


Figure  373.    Aspirating  Attachment  for  the  Author's  Surgical  Pump. 

without  air  bubbles,  the  stop-cock  may  then  be  turned  as  before,  and  the 
cavity  injected  with  a  positive  certainty  that  no  air  has  been  admitted. 

As  it  is  difficult  to  construct  stop-cocks  that  are  absolutely  air-tight,  the 
use  of  the  one  shown  in  the  illustration  should  be  avoided  excepting  in 
cases  where  it  is  necessary  to  inject  the  cavity  with  an  antiseptic  solution. 
It  is  not  required  when  the  instrument  is  used  simply  as  aspirator. 

Rubber  Bulb  Aspirators. 

These  may  be  procured  of  various  patterns,  the  one  shown  by  figure  374 
being  perhaps  the  most  practical.  It  consists  of  a  rubber  bulb  terminating 
in  a  "T"-shaped  joint  in  which  are  included  two  automatic  working  valves, 
one  the  reverse  of  the  other.  To  each  end  of  this  joint  a  rubber  tube  is 
attached,  one  leading  to  the  needle,  the  other  to  the  receptacle  for  the 
aspirating  fluid. 

The  arrangement  of  the  valves  is  such  that  by  compressing  the  bulb  the 
contained  air  is  forced  out  of  the  side  opposite  the  needle.  On  releasing 
the  bulb  it  acts  as  an  exhaust,  drawing  it  through  the  needle  into  the  bulb. 
By  repeating  the  compression  of  the  bulb  it  acts  as  a  pump,  and  affords 
quite  satisfactory  results. 

The  objections  to  the  apparatus  are  its  limited  power,  the  labor  nec- 
essary to  sterilize  it  and  the  fact  that  the  pressure  is  not  continuous.  Its 


ASPIRATION. 


205 


chief  advantage  is  its  low  price.  In  the  absence  of  an  apparatus  of  this 
character,  if  the  surgeon  be  provided  with  an  aspirating  needle  or  trocar, 
an  ordinary  bulb  syringe  may  be  attached  and  reasonably  good  results 
obtained. 

Aspiration  by  Siphon. 

This  may  be  secured  by  various  methods.  The  one  usually  employed 
consists  in  the  use  of  a  suitable  needle  or  trocar,  a  two-way  stop-cock, 
reservoir  filled  with  a  sterile  solution,  and  rubber  tubing  for  the  necessary 
connections.  The  various  parts,  ready  for  an  operation,  are  shown  in  fig- 
ure 375. 

In  the  absence  of  a  two-way  stop-cock,  a  bifurcated  tube  of  any  material 
or  pattern  will  answer  the  same  purpose.  Before  the  introduction  of  the 
trocar  the  stop-cock  should  be  turned  and  the  trocar  lowered  that  fluid  may 
pass  from  the  reservoir  through  the  canula.  If  both  tube  and  canula  be 


Figure  374.    Lentz's  Aspirator. 

filled  with  fluid  at  the  time  of  the  perforation,  there  will  be  no  danger  of 
introducing  air  into  the  cavity.  As  soon  as  the  fluid  has  been  tapped  by 
the  needle,  the  stop-cock  may  be  turned  in  the  opposite  direction,  thus  per- 
mitting the  outward  flow  of  the  contained  fluid  toward  the  bottle.  When 
all  has  passed,  the  sac  may  be  washed  out  by  turning  the  stop-cock  to  its 
original  position  and  admitting  the  antiseptic  solution.  This  fluid  may  be 
withdrawn  in  the  same  manner  as  the  original  contents  of  the  sac.  Care 
should  be  taken  during  the  progress  of  the  operation  to  see  that  the  escape 
tube  is  first  filled  with  fluid  and  then  that  its  distal  end  is  kept  below  the 
water  surface.  This  precaution  may  prevent  a  reflex  action  and  aspiratioq 
of  air  into  the  cavity. 

Aspirating  Needles  and  Trocars. 

Both  needles  and  trocars  are  used  for  aspiration.  In  selecting  an 
aspirating  needle  it  is  well  to  remember  that  it  should  be  as  small  as  is 
consistent  with  the  nature  and  quantity  of  the  fluid  to  be  withdrawn.  The 
point  and  cutting  edges  of  the  needle  should  be  well  sharpened  and 
smoothed,  and  care  should  be  taken  to  see  that  the  inner  edge  or  margin  of 
the  lumen  be  well  rounded  in  order  that  the  introduction  of  the  needle  may 


206 


PARACENTF.SIS. 


not  act  as  a  hollow  punch  and  thus  remove  a  small  section  of  the  cavity 
wall. 

The  extreme  point  of  the  needle  should  be  as  thin  and  flat  as  possible, 
that  it  may  form  a  slit-like  opening-  similar  to  a  knife-blade  incision,  so  that 
if  the  needle  be  introduced  in  an  oblique  direction,  the  small  flap  cut  by  the 
penetration  of  the  cavity  wall  will  assist  in  the  self-closing  of  the  needle 
wound. 

This  desirable  shape  of  the  needle  point  may  be  obtained  if  the  cutting 
surface  be  ground  in  a  concave  form  as  shown  in  figure  376.  When  used 


Figure  375.    Woods'  Siphon  Aspirator. 

in  the  bladder,  a  needle  of  this  character  should  be  withdrawn  before  all 
the  urine  has  escaped,  that  the  contracting  wall  may  not  close  upon  the 
sharp  end  of  the  needle  and  thus  produce  laceration  of  the  mucous  lining. 
Aspirating  needles  may  be  obtained  of  almost  any  size  from  the  smallest 
caliber  used  for  hypodermic  purposes,  to  the  large  needles  frequently 
employed  by  embalmers.  Ordinary  aspirating  outfits  usually  contain  three 
or  four  needles  about  numbers  16,  13,  n  and  9,  Brown  &  Sharp's  gauge,  or 
about  numbers  3,  5,  7  and  8,  French  scale. 


Figure  376.    Plain  Aspirating  Needles. 

Aspirating  Trocars  differ  from  needles  in  possessing  a  solid  perforator 
inclosed  in  a  thin  metallic  canula.  The  rod  in  these  instruments  pro- 
jects a  short  distance  beyond  the  canula  and  is  generally  sharpened  to  a 
triangular  point,  having  three  flat  faces  with  cutting  edges. 

Trocars  are  usually  preferred  in  cases  where  a  large  quantity  of  fluid  is 
to  be  evacuated.  The  smooth  end  of  such  an  instrument  in  the  pleural 
cavity  will  avoid  injury  to  the  lung  tissue.  In  the  bladder  it  will  not  only 
accomplish  the  same  result,  but  it  will  prevent  the  opposite  wall  from  being 
transfixed,  for,  as  the  bladder  contracts  under  the  influence  of  the  escaping 
urine,  it  must  necessarily  press  upon  the  point  of  whatever  instrument 
has  been  introduced.  The  smooth  distal  end  of  the  canula  enables  the 
surgeon  to  move  it  about  in  the  cavity,  thus  permitting  the  withdrawal  of 
all  residual  contents.  Trocars  for  aspirating  purposes  are  usually  of  three 
forms,  known  as  plain,  Emmet's  and  with  stop-cock. 


ASPIRATING    TROCARS.  207 

The  Plain  Trocar,  shown  in  figure  377,  consists  of  a  triangular-pointed 
solid  needle  surrounded  by  a  thin,  closely  fitting  canula.  This  pattern  is 
now  seldom  employed  for  aspirating  purposes,  because  its  use  necessitates 
the  introduction  of  the  trocar  and  withdrawal  of  its  perforator  before  attach- 
ment to  the  aspirator.  This  in  some  cases  might  permit  the  introduction 


Figure  377.     Plain  Trocar. 

of  air  into  the  cavity.     They  may  be  procured  of  any  desired  size,  those 
usually  employed  being  numbers  5,  7  and  9,  French  scale. 

Fitch's  Dome  Trocar,  as  set  forth  in  figure  378,  practically  consists  of  an 
aspirating  needle  and  stylet,  the  latter  hollow  and  constructed  with  a 
round  or  protruding  point  extending  beyond  the  needle  opening.  The 
instrument  is  intended  to  be  introduced  in  the  same  manner  as  an  ordinary 


Figure  378.    Fitch's  Dome  Trocar. 

aspirating  needle.  After  introduction,  the  probe-pointed  hollow  shaft  may 
be  extended  to  the  point  of  the  needle,  thus  protecting  the  soft  tissues  from 
injury.  By  means  of  a  bayonet  catch  the  inner  canula  may  be  firmly  held 
in  place,  either  within  or  beyond  the  needle  point.  This  instrument  at  one 
time  commanded  a  large  sale.  It  is  objectionable,  however,  because  owing 
to  the  double  walled  canula,  the  instrument  necessitates  a  large  incision 
when  compared  with  the  amount  of  fluid  that  can  be  drawn  through  it;  in 


Figure  379.    Emmet's  Trocar. 

other  words,  the  aspirating  channel  is  small  compared  with  the  external 
diameter  of  the  instrument. 

Emmet's  Trocar,  as  delineated  in  figure  379,  differs  from  the  one  de- 
scribed by  figure  377,  in  being  constructed  in  such  a  manner  that  it  may  be 
attached  to  an  aspirator  before  its  introduction.  It  consists  of  a  straight 
canula  somewhat  longer  than  those  of  plain  pattern,  to  which  is  joined  at  a 
point  near  its  proximal  end,  a  side  tube  to  which  the  aspirator  connection 
may  be  made.  This  tube  forms  a  bifurcation  in  the  lumen  of  the  main 


a 


Figure  380.    Getz'  Improved  Trocar. 

canula.  A  suitable  packing  is  closely  pressed  around  the  trocar  shaft,  that 
when  the  perforator  is  withdrawn,  the  point  will  rest  within  the  chamber 
at  its  proximal  ending,  forming  an  air-tight  joint.  Trocars  of  this  pattern 
may  be  procured  of  any  size,  those  usually  found  in  the  market  arranged 
for  use  with  aspirators,  being  about  numbers  9  and  n,  French  scale. 

Getz'  Improved  Trocar,  as  shown  by  figure  380,  presents  a  new  feature  in 
the  construction  of  these  instruments.  It  is  claimed  that  when  using  the 
ordinary  patterns  of  trocars,  there  is  no  means  of  knowing  just  when  the 


208 


PARACENTESIS. 


instrument  has  perforated  the  cavity  to  be  tapped,  without  withdrawing 
the  trocar  from  the  canula,  excepting  as  indicated  by  the  amount  of  resist- 
ance encountered.  In  such  cases,  if  the  cavity  has  been  properly  entered, 
no  inconvenience  will  result.  On  the  other  hand,  if  such  is  not  the  case,  it 
is  necessary  to  re-introduce  the  trocar  and  make  further  attempts  at  per- 
foration. 


Figure  381.    Aspirating  Trocar  with  Stop-cock. 

By  referring  to  figure  380,  it  will  be  seen  that  this  trocar  is  con- 
structed with  a  shaft  having  a  smaller  diameter  that  the  perforating  point. 
The  latter  portion  of  the  instrument  is  short.  A  side  opening  is  provided 
in  the  canula  near  its  distal  extremity,  so  located  as  to  form  a  passage 
by  which  fluid  from  the  tapped  cavity  may  pass  through  the  canula  while 


Figure  382.    Scoop  Trocar. 

the  trocar  is  in  position.  This  passage  is  small  and  is  intended  only  to 
serve  a  diagnostic  purpose,  to  determine  when  fluid  is  encountered.  In  all 
other  respects  the  instrument  is  a  duplicate  of  the  pattern  of  Emmet  pre- 
viously described. 

The  Aspirating  Trocar  with  Stop-cock,  traced  in  figure  381,  differs  from 
the  design  of  Emmet  in  being  constructed  with  an  air-tight  stop-cock 
between  the  bifurcation  and  the  packing  chamber.  The  stop-cock  is  so 
adjusted  that  the  perforating  rod  passes  directly  through  its  central  shaft. 


Figure  383.    Reversible  Trocar. 


After  the  insertion  of  the  canula  and  withdrawal  of  the  point  as  far  back  as 
the  packing  chamber,  the  stop-cock  is  turned,  so  that  all  connection  in  a 
backward  direction  is  closed,  thus  excluding  all  possibility  of  air  entering 
the  instrument  at  this  point.  It  is  a  better  appliance  than  the  Emmet  pat- 
tern. Like  the  latter,  it  may  be  procured  in  any  desired  size,  those  usually 
in  use  being  numbers  9,  n  and  13,  French  scale. 

TAPPING  WITHOUT  VACUUM  FORCE. 

This  consists  in  introducing  a  trocar,  hollow  needle  or  similar  instrument 
into  the  cavity  containing  the  fluid.  Trocars  originally  consisted  of  trian- 
gular pointed  instruments  used  to  puncture  the  wall  of  a  cyst,  organ  or 
abscess,  for  the  purpose  of  evacuating  any  contained  fluid.  Generally  such 
trocars  were  constructed  with  an  outer  canula,  the  latter  designed  to  re- 
main within  the  wound,  thus  supplying  a  channel  for  fluid  escape. 

The  term  trocar  as  now  employed  covers  a  wider  field  as  tubes  with  tips 


TAPPING    WITHOUT    VACUUM    FORCE. 


209 


elongated,  pointed  and  with  lateral  openings  are  by  some  authors  called 
by  this  name. 

Trocars  for  special  purposes,  such  for  instance  as  paracentesis  of  the 
abdomen,  cornea,   etc.,  will  be  found    described   in  the  various  chapters 


Figure  384.     Pocket  Case  Trocar. 

devoted  to  regional  surgery.  Those  selected  for  illustration  in  this  chapter 
consist  of  patterns  that  may  be  employed  for  general  purposes. 

The  Scoop  Trocar,  represented  in  figure  382,  consists  of  a  suitable  shaft, 
point  and  canula,  the  latter  terminating  in  a  scoop  or  spout  of  such  form 
that  it  may  be  used  to  conduct  the  flow  of  liquid  into  a  basin  or  other 
receptacle.  The  better  class  of  these  instruments  is  provided  with  a 
metallic  cap  by  means  of  which,  when  not  in  use,  the  point  is  protected 
from  injury.  As  ordinarily  manufactured,  they  may  be  obtained  in  sizes 
varying  from  13  to  21,  French  scale. 

The  Reversible  Trocar,  as  displayed  in  figure  383,  consists  of  a  shaft,  point 
and  canula,  the  latter  provided  with  a  screw  of  exactly  the  same  size  as  the 


Figure  388.'    Set  of  Three  Nested  Trocars. 

canula  shaft.  This  construction  enables  the  operator  to  reverse  the  canula, 
so  that  the  hollow  handle  may  serve  as  a  shield  or  protector  for  the  instru- 
ment when  not  in  use.  The  sizes  vary  from  12  to  21,  French  scale. 

The  Pocket-Case  Trocar,  as  indicated  in  figure  384,  differs  from  the  pat- 
tern last  described  in  that  the  handle  consists  of  a  slender  tube  closed 
at  one  end.  The  instrument  is  reversible  and  may  be  carried  under  the 
loop  of  a  small  pocket-case.  The  sizes  are  usually  from  7  to  10,  French  scale. 

The  Set  of  Three  Nested  Trocars,  set  forth  in  figure  385,  consists  of  a  set 
of  three,  one  nesting  within  the  other  and  all  of  a  reversible  tip  similar  to 
figure  383.  The  instruments  when  not  in  use  are  held  in  place  by  a  fenes- 


Figure  386.     Set  of  Four  Nested  Trocars. 

trated  shield,  attached  to  the  handle  by  means  of  a  screw  joint.  Modern 
patterns  include  a  spiral  spring  surrounding  the  outer  or  larger  canula  by 
which  the  point  of  the  latter  is  prevented  from  striking  against  the  inner 
surface  of  the  hollow  handle.  The  usual  sizes  are  about  numbers  5,  9  and 
13,  French  scale. 

The  Set  of  Four  Nested  Trocars,  as  it  appears  in  figure  386,  does  not  differ 
materially  from  the  pattern  last  described.  It  is  generally  constructed  with 
an  octagonal  handle  and  shield.  The  sizes  are  usually  5,  9,  14  and  19, 
French  scale. 

14 


CHAPTER  XI. 


INJECTION  APPARATUS. 


Under  this  head  we  will  include  the  appliances  used  for  deep  intra-tissue 
injection,  which  are  not  embraced  in  the  chapters  devoted  to  paracentesis  or 
hypodermic  injection.  Many  instruments  may  be  utilized  for  both  injec- 
tions and  aspirations.  Several  such  patterns  will  be  found  described  on 
pages  201  to  203. 

Senn's  Injection  Syringe,  as  shown  by  figure  387,  consists  of  a  medium- 
sized  rubber  bag  of  the  valveless  Politzer  pattern,  connected  by  means  of  a 
rubber  hose  with  a  cylindrical  glass  reservoir,  stop-cock  and  suitable  needles 
and  trocar.  The  reservoir  is  of  about  one  ounce  capacity  and  is  graduated 
in  drachms. 

The  injecting  force  consists  of  an  elastic  column  of  air  propelled  by 
forced  contraction  of  the  rubber  bulb.  If  the  cylinder  is  held  in  an  upright 


Figure  387.    Senn's  Injection  Syringe. 


Figure  388.    Heuter's  Infuser. 


position,  the  movement  of  the  overflowing  fluid  may  be  carefully  noted 
and  the  quantity  passed,  accurately  determined. 

As  it  possesses  no  valves  or  pistons,  this  instrument  is  not  liable  to  get 
out  of  order.  Its  parts  are  easily  separable  and  consequently  readily 
sterilized.  In  intra-articular  injections,  the  instrument  is  particularly 
safe,  because  if  properly  managed  there  is  no  danger  from  the  introduction 
of  air,  nor  is  there  any  likelihood  that  sufficient  force  will  be  exerted  to 
rupture  the  capsule.  By  introducing  the  needle  while  the  rubber  bulb  is 
compressed,  the  instrument  may  be  used  as  an  aspirator,  thus  answering 
a  two-fold  purpose. 

210 


INJECTION    APPARATUS. 


211 


To  prepare  the  syringe  for  use,  the  rubber  cap  should  be  removed  from 
the  top  of  the  reservoir,  the  stop-cock  closed,  and  the  cylinder  filled  with  the 
fluid  to  be  injected,  after  which  the  cap  should  be  replaced.  Before  mak- 
ing perforation  with  the  needle,  the  stop-cock  should  be  opened  and  the  air 
expelled  from  the  hose,  stop-cock  and  needle,  permitting  them  to  fill  with 
the  fluid  by  force  of  gravity.  After  the  introduction  of  the  needle,  the 
fluid  may  be  forced  through  the  needle  by  hand  pressure  on  the  bulb,  the 
amount  injected  being  shown  by  the  scale  on  the  reservoir.  That  no  air 
may  pass  through  the  needle  the  cylinder  should  be  kept  above ;  that  is,  on 
a  higher  plane  than  the  needle. 

Heuter's  Infuser,  as  manifest  in  figure  388,  comprises  a  graduated  glass 
cylinder  connected  by  means  of  a  rubber  hose  with  a  long  slender  needle 
provided  with  numerous  small  lateral  openings.  The  reservoir  is  open  at 


Figure  389.     Murphy's  Apparatus  for  the  Injection  of  Nitrogen  Gas  into  the  Pleural  Cavity. 

the  upper  end  and  is  graduated  in  drachms.  The  force  employed  is 
gravity,  the  amount  of  which  depends  on  the  height  of  the  cylinder  above 
the  needle  point.  This  height  must  be  regulated  according  to  the  density 
of  the  fluid  to  be  infused  and  the  character  of  the  tissue  to  be  saturated. 

Murphy's  Apparatus  for  the  Injection  of  Nitrogen  Gas  into  the  Pleural 
Cavity,  as  represented  in  figure  389,  consists  of  a  tank  of  compressed 
nitrogen  gas,  a  spirometer  into  which  the  gas  is  liberated  and  from  which 
it  is  injected  through  a  trocar,  the  whole  being  connected  by  pieces  of 
rubber  hose.  The  cylinder  is  of  copper,  about  10  inches  in  height  and  5 
inches  in  diameter,  and  is  provided  with  a  registering  gauge  and  a  close 
fitting  one-way  pin-hole  stop-cock.  The  spirometer  is  of  the  usual  gas 
storage  pattern,  provided  with  inlet  and  outlet  tubes  that  connect  with  the 
upper  surface  of  the  inverted  cylinder.  These  furnish  means  for  filling  the 
tank  and  injecting  the  desired  quantity.  The  latter,  by  graduations  on 
pillars  that  serve  as  guides  may  be  accurately  determined.  The  stop-cock 
may  be  either  of  the  Emmet  pattern,  as  exhibited  in  figure  379,  or  that  de- 
signed by  Fitch,  as  delineated  in  figure  378. 


CHAPTER  XII. 


TRANSFUSION    OF    BLOOD    AND    INTRA- 
VENOUS INJECTION. 

This  consists  in  introducing  blood  into  the  circulatory  channels.  It 
may  be  employed  in  patients  suffering  from  the  effects  of  profuse  hemor- 
rhage, or  where,  from  any  cause,  a  reciprocal  quantity  of  blood  is  required 
to  replace  any  that  may  have  been  withdrawn  by  accident  or  otherwise. 
Thence  transfusion  may  be  either  arterial  or  venous. 

This  operation,  once  advocated  not  only  for  the  purpose  of  restoring 
arterial  pressure,  but  for  the  relief  of  such  forms  of  disease  as  were  supposed 
to  have  their  origin  in  the  blood,  is  now  seldom  employed.  Not  only  have 
the  general  results  proved  unsatisfactory,  but  it  has  been  demonstrated  that 
in tra- venous  injection  of  a  salt  solution  answers  equally  as  well  as  the 
transfusion  of  blood  and  is  not  attended  by  the  grave  dangers  to  life  that 


Figure  390.     Aveling's  Apparatus  for  Direct  Blood  Transfusion. 

threaten  the  older  operation.  Transfusion  may  be  performed  by  two 
methods:  Direct  or  immediate  transfusion,  or  indirect  or  mediate  trans- 
fusion. 

Direct  Transfusion  is  the  act  of  transferring  blood  from  the  circulation 
of  one  person  directly  to  that  of  another  through  a  suitable  tube  and 
canula  without  air  exposure.  Transfusion  from  animals  to  man  has  occa- 
sionally been  employed,  but  is,  we  believe,  no  longer  practiced.  This  oper- 
ation requires  the  utmost  care  in  the  manipulation  of  the  apparatus 
employed,  owing  to  the  tendency  of  the  blood  to  coagulate  and  form  clots, 
these  in  turn  producing  embolisms. 

For  this  reason  direct  transfusion  has  gradually  been  replaced  by  the 
indirect  method  in  which  the  blood  to  be  transferred  is  defribrinated  before 
introduction. 

Direct  Transfusion. 

An  apparatus  for  this  purpose  should  contain  neither  valves  nor  pistons, 
and  should  present,  as  nearly  as  possible,  a  course  through  which  the  blood 
may  flow  readily  and  uninterruptedly. 


INDIRECT     TRANSFUSION. 


213 


Aveling's  Transfusion  Apparatus,  as  pictured  in  figure  390,  consists  of  a 
rubber  hose  about  18  inches  in  length,  in  the  center  of  which  is  a  small 
rubber  valveless  bulb  having  an  injecting  capacity  of  about  2  drachms.  To 
each  of  the  terminal  points  of  the  rubber  hose  is  attached  a  silver,  bevel- 
pointed  canula  of  such  shape  and  size  as  to  be  easily  introduced  into  the 
blood-vessel.  Two  stop-cocks  are  connected  in  the  line  of  tubing,  each  be- 
ing located  in  close  proximity  to  one  of  the  canulas. 

To  operate  the  instrument  it  is  necessary  to  first  fill  the  bulb,  hose  and 
canulas  with  a  warm  normal  salt  solution,  preferably  at  atemperature  of  105° 
Fahr.  Great  care  should  be  exercised  to  force  all  air  from  the  instrument 
before  connection  is  made.  An  exposed  vein  in  the  arm  of  both  donor  and 
patient  may  then  be  opened  and  one  of  the  canulas  while  filled  with  fluid, 
introduced  into  each.  It  must  not  be  forgotten  that  the  instrument  pos- 
sesses no  valves  and  that  the  operator  by  alternately  compressing  first  one 
end  of  the  tube  and  then  the  other,  must  compensate  for  the  absence  of 
these  parts.  As  soon  as  the  canulas  are  in  place,  the  operator  should  com- 
press with  the  thumb  and  finger,  that  portion  of  the  rubber  hose  nearest  to 
the  donor.  By  squeezing  the  bulb  its  contents  will  be  forced  into  the 
vein  of  the  patient,  then  by  compressing  the  end  of  the  hose  nearest  to  the 
patient  and  relaxing  the  one  first  compressed,  the  bulb  will  fill  from  the 
donor  after  which,  as  in  the  first  instance,  its  contents  may  be  forced  into 


Figure  391.    Allen's  Apparatus  for  Indirect  Transfusion. 


Figure  392.    Apparatus  for 
Intra  Venous  injection. 


the  circulation  of  the  patient.  The  amount  injected  may  be  estimated  by 
counting  the  number  of  bulb  compressions,  remembering  that  each  com- 
pression will  inject  about  2  drachms. 

Indirect  Transfusion. 

This  consists  in  introducing  defibrinated  blood  from  a  container  into  the 
circulation  of  the  patient.  As  the  dangers  of  coagulation  are,  by  this 
method,  reduced  to  a  minimum,  this  operation  is  considered  an  improve- 
ment on  direct  transfusion. 

The  blood  from  the  donor  in  this  operation  is  first  drawn  by  the  ordinary 
methods  of  blood-letting,  into  a  glass  or  porcelain  vessel,  that  is  and  must 
be  maintained  at  a  temperature  of  from  105°  to  no0  Fahr.  The  blood  is 
then  defibrinated  by  being  rapidly  stirred  or  whipped.  This  may  be  ac- 
complished with  a  small  wire  brush  or  rotary  egg-beater,  after  which  the 


214  TRANSFUSION    OF    BLOOD    AND    INTRA-VENOUS    INJECTION. 

blood  is  filtered  through  a  linen  cloth.  The  container,  stirring  utensil, 
cloth,  etc.,  must  all  have  been  previously  sterilized  and  all,  whe,n  in  use, 
should  be  kept  at  the  temperature  above  mentioned.  After  filtering,  the 
blood  may  be  injected  with  the  apparatus  of  Aveling  or  with  an  ordinary 
syringe  supplied  with  a  proper  canula. 

Allen's  Apparatus  for  Indirect  Transfusion,  consists  of  a  receiver  with 
syringe  and  canula.  The  receiver  is  a  German  silver  cup  about  6  inches  in 
height  by  6  in  diameter.  The  cup  is  divided  into  two  compartments,  the 
lower  used  as  a  container  for  hot  water,  the  upper  to  receive  the  blood  for 
injection.  The  vessel  receiving  the  latter  is  conical  in  form  as  shown  by 
figure  391.  When  in  use,  the  lower  basin  is  filled  with  warm  water 
and  the  blood  drawn  into  the  receiver  and  defibrinated  by  agitation.  After 
this  the  blood  is  strained  through  a  piece  of  sterilized  linen,  and  returned 
to  the  receiver.  The  water  compartment  is  filled  by  means  of  an  inlet  pipe 
attached  to  its  upper  margin.  A  thermometer  placed  in  the  side  of  the 
vessel  indicates  the  temperature  of  the  water.  The  syringe  is  glass  of  the 
piston  type,  with  metal  bands  and  aseptible  packing.  The  canula  is  of  the 
usual  pattern  and  attached  by  slip  joint.  The  apparatus  furnishes  a  very 
convenient  outfit  for  this  operation. 

Intra- Venous  Injection. 

This  consists  in  introducing  a  quantity  of  salt  solution  or  other  fluid 
into  the  circulatory  channels.  It  is  employed  to  restore  a  proper  volume 
and  consequent  arterial  tension  impaired  by  a  lost  blood  supply. 

This  operation  is  now  generally  accepted  as  an  improvement  on  any 
form  of  transfusion.  The  solution  usually  employed  consists  of  one  drachm 
of  pure  salt  dissolved  in  one  pint  of  sterilized  water,  which,  when  intro- 
duced, should  be  at  a  temperature  of  about  105°  Fahr. 

The  Apparatus  for  Intra-Venous  Injection,  as  portrayed  in  figure  392,  con- 
sists of  a  small  funnel,  a  piece  of  rubber  tubing  18  inches  in  length,  and  a 
canula  as  shown  by  figure  390.  The  latter  may  be  of  hard  rubber  or  silver. 
To  inject  with  this  apparatus  it  is  necessary  only  to  introduce  the  canula 
into  the  opened  vein,  first  having  filled  the  funnel,  tube  and  pipe  with  the 
fluid.  A  sufficient  pressure  will  be  obtained  if  the  funnel  be  held  15  or  18 
inches  above  the  point  of  entrance.  In  order  to  avoid  the  introduction  of 
air,  care  must  be  taken  to  see  that  the  funnel  is  not  permitted  to  become 
empty.  It  should  be  closely  watched  and  additions  of  fluid  frequently 
made. 

From  one  to  three  pints  may  be  injected.  Like  the  apparatus  employed 
for  transfusion,  all  parts  must  be  aseptic,  in  fact,  preparations  should  be 
made  the  same  as  for  an  aseptic  minor  operation. 


CHAPTER 


ARTIFICIAL  RESPIRATION. 

Artificial  or  forced  respiration  is  required  in  cases  where,  from  any  cause, 
the  action  of  the  respiratory  organs  is  partially  or  completely  in  a  state  of 
temporary  suspension. 

An  apparatus  for  this  purpose  may  consist  of  a  form  of  bellows  or  other 
appliance,  by  which  a  uniform  quantity  of  air  may  be  regularly  injected 
into  the  lungs,  from  which  it  may  as  regularly  escape  by  natural  muscular 
contraction  or  forced  compression.  It  may  be  found  useful  in  cases  where 
life  is  threatened  by  temporary  paralysis  of  the  respiratory  centers,  conse- 


Figure  393.    Fell's  Apparatus  for  Artificial  Respiration. 

quent  upon  drowning,  asphyxia,  poisoning  from    opium    or  its  alkaloids, 
profound  anesthetization,  etc. 

It  is  claimed,  although  there  is  no  proof  that  it  was  ever  utilized,  that 
the  first  satisfactory  apparatus  for  this  purpose  was  devised  by  Hunter,  who 
constructed  a  double-acting  bellows  connected  by  a  rubber  tube  with  a  suit- 
able face-shield  in  such  a  manner  that  with  each  compression  and  expan- 
sion of  the  bellows,  air  was  forced  into  and  drawn  from  the  lungs,  the  ex- 
haled air  being  forced  into  the  atmosphere  that  the  in-going  current  might 
always  be  fresh.  Fell  improved  upon  the  plan  of  Hunter  and  by  continued 

215 


216 


ARTIFICIAL     RESPIRATION. 


experiments  and  the  contribution  of  several  valuable  papers,  has  done  much 
to  perfect  and  prove  the  practicability  of  the  methods  employed  for  this 
purpose,  and  to  bring  this  means  of  saving  life  prominently  before  the  med- 
ical profession. 

Such  appliances  as  are  employed  by  the  accoucheur  in  cases  ot  asphyxia 
in  newborn  infants  will  be  found  described  in  the  chapter  devoted  to  Obstet- 
rical Surgery. 

Fell's  Apparatus,  as  explained  by  figure  393,  consists  of  a  hand  bellows 
connected  by  a  suitable  hose  with  an  air-control  valve  and  face-shield. 

By  properly  working  the  bellows  while  making  finger  pressure  on  the 
valve,  the  lungs  may  be  filled  to  their  full  capacity,  after  which  the  air  is  per- 
mitted to  escape  by  natural  means  by  releasing  the  pressure.  For  the  next 
inspiration,  pressure  with  the  fingers  is  again  made,  and  so  on. 

While  an  apparatus  with  a  face-shield  connection  will  operate  satisfac- 
torily in  most  cases,  some  will  be  encountered  wherein  it  will  not  be  effec- 
tive. Air  forced  through  the  nose  or  mouth  is  sometimes  obstructed  by  a 
backward  movement  of  the  tongue  and,  in  a  few  patients,  the  larynx  be'- 
comes  obstructed  by  natural  causes,  probably  due  to  lack  of  expansion.  In 


Figure  394.    Fell's  Tracheotomy  Tube,  for  Use 
in  Artificial  Respiration. 


Figure  395.    O'Dwyer's  Intubation  Attachment, 
for  Use  in  Artificial  Respiration. 


such  cases,  and  through  the  specially  valuable  influence  of  complete  control 
of  the  respiration,  tracheotomy  was  found  necessary,  and  to  meet  this  con- 
dition Fell  devised  a  special  tracheotomy  tube  for  insertion  and  connection 
with  the  stop- cock  and  bellows. 

Fell's  Tracheotomy  Tube  for  Use  in  Artificial  Respiration,  as  drawn  in 
figure  394,  differs  from  those  employed  in  ordinary  cases,  in  having  a  ring 
attached  to  its  lower  margin  that  the  tube  may  fit  more  closely  the  lumen 
of  the  trachea. 

These  rings  are  of  various  sizes,  that  the  tube  may  be  adjusted  to  differ- 
ent patients.  This  attachment  proved  a  still  further  advance  in  the  perfec- 
tion and  application  of  this  apparatus.  Fell  advocated  in  his  earlier  writ- 
ings an  intubation  tube,  but  did  not  utilize  it  in  his  work.  Joseph  O'Dxvycr, 
wishing  to  avoid  the  operation  of  tracheotomy,  constructed  a  special  intuba- 
tion ttibe  to  be  employed  instead  of  tracheotomy,  which  produces  equally 
as  good  results,  but  is  seldom  of  value  where  the  face-shield  is  employed. 

O'Dwyer's  Intubation  Attachment,  for  use  in  artificial  and  forcible  res- 
piration, as  delineated  in  figure  395,  consists  of  a  slender  canula  curved  like 
a  male  catheter,  terminating  in  a  cone-shaped  tip  of  a  size  proper  to  effect 
complete  closure  of  the  trachea.  Various  sizes  of  these  tips  may  be  pro- 
vided with  a  single  tube.  The  tube  is  bifurcated  near  its  proximal  end. 
To  the  side  tube  a  rubber  hose  and  plain  foot  bellows  may  be  attached. 


INTUBATION — FORCED  RESPIRATION.  217 

Three  finger  rings  placed  just  distal  to  the  bifurcation  enable  the  operator 
to  secure  full  control  of  the  tube  and  thus  prevent  its  accidental  ejection. 
By  placing  the  fingers  in  the  rings  referred  to,  with  the  thumb  over  the  main 
opening  in  the  proximal  end  of  the  tube,  respiratory  movements  may  be 
effectually  controlled. 

By  compressing  the  bellows,  the  thumb  at  the  same  time  closing  the 
opening  of  the  tube,  air  may  be  forced  into  the  lungs,  which  will  escape 
upon  removal  of  the  thumb.  This  arrangement  appears  to  be  an  improve- 
ment upon  tracheotomy,  and  a  tube  of  this  character  should  accompany 
each  outfit. 

The  use  of  an  apparatus  for  this  purpose  should  be  continued  even  in 
cases  where  no  natural  respiratory  movements  are  for  some  time  noticeable, 
and  the  apparatus  must  be  operated  to  correspond  as  far  as  possible  with 
the  regular  breathing  of  the  patient. 


Figure  396.     Richardson's  Double  Bellows  for  Forced  Respiration. 

Richardson's  Double  Bellows  for  Forced  Respiration,  as  traced  in  figure 
396,  illustrates  a  double  bellows  used  for  producing  artificial  respiration. 
It  consists  of  two  elastic  bulbs,  to  each  of  which  a  rubber  tube  is  attached, 
the  two  terminating  in  a  siugle  tube.  The  rubber  bulbs  are  so  regulated 
by  valves  that  air  may  be  forced  into  the  lungs  by  the  compression  of  one 
and  withdrawn  by  the  compression  of  the  other.  When  in  use,  the  single 
terminal  tube  is  introduced  into  one  nostril,  the  other  nostril  and  the  mouth 
being  closed.  By  alternately  compressing  first  one  bulb  and  then  the 
other,  the  respiratory  current  'may  be  artificially  established.  In  actual 
operation  this  appliance  has  not  proved  successful  to  any  great  extent. 


CHAPTER  XIV. 


MECHANICAL  CAUTERIZATION. 

This  is  employed  in  surgery  to  destroy,  remove  or  sever  tissues,  as  a 
counter-irritant  and  as  a  hemostatic.  For  the  latter  purpose  it  is  seldom 
employed,  excepting  where  deep-seated  tissues  are  involved  or  where  ves- 
sels can  not  be  ligated  with  safety.  Three  forms  are  applicable :  Flame 
heated  irons,  thermo-cautery,  and  electro-cautery. 


Figure  397.    Plain  Cautery  Irons. 

Flame  Heated  Irons. 

The  application  of  flame  heated  irons  is  described  by  authors  generally 
as  "The  actual  cautery."  As  mechanical  cauterization  in  any  form  is 
actual,  the  term  is  general  and  not  specific.  The  irons  necessary  may  be  of 
any  desired  size  or  shape.  They  may  be  heated  in  the  flame  of  a  spirit 
lamp,  gas  jet,  or  by  other  suitable  means.  The  heat  may  vary  from  a  dull 
red  to  white,  according  to  the  size  of  the  cautery  point  and  the  nature  of 
the  application  required. 


Figure  398.    Self-Blowing  Cautery  Lamp. 

The  Plain  Cautery  Irons,  sketched  in  figure  397,  constitute  the  four 
most  useful  patterns. 

"A"  and  "C"  are  of  bulbous  form,  well  adapted  for  controlling  hem- 
orrhage. "B"  consists  of  a  circular  disc,  usually  employed  for  cauterizing  a 
large  surface,  such  as  a  stump  or  pedicle,  while  "D"  is  a  special  pattern 
used  principally  in  bone  surgery.  A  universal  handle  is  shown  by  "E." 
The  length  of  the  irons  is  usually  about  10  inches. 

218 


FLAME  HEATED  IRONS. 


219 


The  Self-Blowing  Cautery  Lamp,  as  illustrated  in  figure  398,  is  a  con- 
venient appliance  though  not  absolutely  necessary. 

While  cautery  irons  may  be  heated  in  any  ordinary  flame,  more  satisfac- 
tory results  will  be  obtained  by  applying  some  form  of  a  gas-generating  self- 
blowing  lamp.  Among  the  different  varieties  used  for  this  purpose,  the  one 
here  referred  to  is,  perhaps,  the  best  and  most  simple. 

It  consists  of  a  circular  cup  2  inches  in  height  and  3  inches  in  diam- 
eter. A  ring-shaped  boiler  ^  inch  thick  and  i  inch  deep  is  fastened  on  the 
inside  of  the  cup,  flush  with  the  top  or  rim.  A  metallic  tube  about 
^  of  an  inch  in  diameter  projects  from  the  upper  surface  of  the  boiler, 
and,  curving  over  into  the  center  of  the  cup,  extends  to  the  bottom,  where  it 
is  bent  so  as  to  point  directly  upward  in  the  center  of  the  cup. 

This  tube  terminates  in  a  fine  needle-sized  opening  that  forms  a  spray 
point.  This  construction  leaves  a  considerable  space  in  the  lower  half 
of  the  cup  beneath  the  boiler  and  a  circular  space  il/2  inches  in 
diameter  inside  the  boiler.  A  screw  cap  covers  the  opening  in  the  boiler, 
through  which  it  may  be  filled  with  alcohol.  To  operate  the  lamp,  it  is  only 
necessary  to  fill  the  boiler  half  full  of  alcohol  and  replace  the  metal  cap. 
Half  an  ounce  of  alcohol  should  then  be  poured  into  the  bottom  of  the  cup 


Figure  399.    The  Improved  Thermo-Cautery. 

and  ignited.  This  flame,  in  from  three  to  five  minutes,  will  produce  sufficient 
heat  in  the  boiler  to  convert  the  alcohol  therein  contained  into  gas, 
which  will  escape  from  the  spray  tube,  its  only  outlet.  The  alcohol  spray, 
issuing  with  some  force  and  ignited  by  the  blaze  in  the  cup,  will  burn  with 
an  intense  heat,  shooting  a  flame  high  into  the  air.  To  heat  a  cautery  iron 
it  will  only  be  necessary  to  place  it  on  the  stand  shown  in  the  engraving 
and  turn  the  hood  so  it  will  deflect  the  flame  backward  and  downward, 
thus  increasing  the  degree  of  heat.  A  safety  valve  in  the  boiler  cup 
insures  the  apparatus  against  accident. 


220  MECHANICAL    CAUTERIZATION. 

Therxno-Cautery. 

This  may  be  secured  by  the  application  of  a  hollow  platinum  point  or 
needle,  so  arranged  that  it  may  be  maintained  at  a  high  degree  of  heat 
by  the  condensation  of  a  benzene  vapor  spray. 

The  original  thermo-cautery,  devised  by  Paquelin,  consisted  of  a  hollow 
platinum  needle  adjusted  to  a  handle  of  non-conducting  material,  so  con- 
nected with  a  double  air  bulb  and  reservoir  that  after  the  needle  had  been 
heated  in  the  flame  of  a  spirit  or  similar  lamp,  a  stream  of  benzene  or  other 
vapor  could  be  forced  into  the  chamber  of  the  needle,  where,  by  the  combus- 
tion of  the  vapor  caused  by  its  contact  with  the  heated  needle,  a  uniform  heat 
could  be  indefinitely  maintained.  This  instrument  thus  constructed  formed 
for  many  years  the  standard  thermo-cautery  of  the  world,  which,  when 
properly  understood,  gave  and  still  gives  almost  universal  satisfaction. 

The  Improved  Thermo-Cautery,  depicted  in  figure  399,  does  not  necessi- 
tate the  use  of  a  spirit  lamp  for  heating  the  needle,  as  by  a  specially  con- 
structed device  and  suitable  cut-off,  a  flame,  sufficiently  intense  for  this 
purpose,  may  be  generated  direct  from  the  reservoir.  As  now  constructed, 


Figure  400.    Pocket  Thermo-Cautery. 

half  a  teaspoonful  of  benzene  is  sufficient,  not  only  for  this  purpose,  but  for 
continuing  the  heat  a  sufficient  length  of  time  to  employ  the  cautery  in 
any  ordinary  surgical  operation.  After  connecting  the  apparatus  as  above 
shown,  and  placing  the  benzene  in  the  reservoir,  the  operator  has  only  to 
turn  the  cut-off  to  the  point  marked  "lamp"  when  a  fine  vapor  of  benzene 
may  be  forced  from  the  opening  by  simple  pressure  of  the  double  bulb. 
When  lighted  this  will  burn  like  the  flame  of  a  gas  jet,  and  is  of  sufficient 
intensity  to  heat  the  cautery  to  a  dull  red  heat,  after  which,  by  turning 
the  cut-off  to  the  point  marked  "burner,"  the  vapor  may  be  forced  through 
the  handle  into  the  point,  heating  the  latter  to  any  desired  temperature. 
After  completing  the  operation,  if  the  cut-off  be  again  turned  to  the  point 
marked  "closed,"  no  further  vapor  will  escape. 

The  apparatus  consists  of  a  metal  reservoir  with  flame  attachment ;  a 
double  bulb  and  rubber  hose,  and  an  insulated  handle  with  two  cautery 
points,  one  large  and  cylindrical  terminating  in  an  oval  face  about  half  an 
inch  in  diameter,  the  other  smaller  and  shorter,  of  a  slender,  flattened  oval 
form,  about  30  millimeters  in  length,  4  millimeters  in  width  and  i% 
millimeters  in  thickness,  terminating  in  a  somewhat  sharp  edge.  This 
point  is  commonly  known  as  a  cautery  knife. 


ELECTRO-CAUTERY.  221 

The  entire  apparatus,  with  directions,  is  contained  in  a  neat  case  7  J^ 
inches  in  thickness,  5  inches  in  width  and  3^  inches  in  height. 

The  Pocket  Thermo-Cautery,  portrayed  in  figure  400,  while  it  employs 
a  separate  lamp,  is  still  much  in  demand  because  of  its  lower  price  and 
compact  form.  A  small  cylindrical  metal  bottle  is  provided  to  carry  a  supply 
of  benzene.  A  similar  shaped  cylinder  is  converted  into  an  alcohol  lamp,  by 
which  the  cautery  point  may  be  at  first  heated.  The  handle,  point  and 
double  bulb  are  connected  practically  as  they  are  in  the  larger  apparatus 
previously  described.  The  point  is  heated  in  the  same  manner  and  the 
heat  maintained  exactly  as  in  the  larger  apparatus. 

The  appliance  consists  of  a  benzene  bottle,  alcohol  lamp,  handle  with 
cut-off,  double  bulb  and  two  cautery  points,  one  a  cautery  knife  as  described 
under  figure  399,  the  other  a  sharp,  straight,  perforating  needle  about 
40  millimeters  in  length  and  4  millimeters  in  thickness  at  its  upper  diam- 
eter, and  terminating  in  a  sharp  point  at  its  lower  extremity,  all  of  which 
are  contained  in  a  soft  leather  case  6^  inches  in  length,  4  inches  in  width 
and  i  y2  inches  in  thickness,  suitable  for  carrying  in  the  pocket. 

Electro-Cautery. 

The  Electro-Cautery  may  be  applied  by  small  electrodes  or  the  wire 
loop,  heated  by  a  storage  battery  or  street  current.  The  necessary  appli- 
ances are  fully  described  in  a  chapter  devoted  to  Electro-Therapeutics. 


CHAPTER  XV. 


RESOLUTION   OF   INFLAMMATION. 

The  symptomatic  treatment  of  both  acute  and  chronic  inflammation,  so 
far  as  it  is  within  the  scope  of  this  work,  may  consist  of  any  of  the  follow- 
ing methods :  Application  and  extraction  of  heat,  blood  letting,  dry  cupping, 
counter-irritation,  ignipuncture  and  parenchymatous  injection. 

APPLICATION  AND  EXTRACTION  OF  HEAT. 

This  consists  in  bringing  in  contact  with  the  inflamed  parts,  substances, 
the  temperature  of  which  is  much  higher  or  lower  than  the  normal  warmth 
of  the  body.  Heat,  like  water,  seeks  an  equilibrium.  If  cloth  or  other 


Figure  401.    Plain  Soft 
Rubber  Water  Bottle. 


Figure  408.    Soft  Rubber  Water  Bottle  for 
Throat. 


Figure  403.    Hemsteger's 
Compress  Protector. 


porous  material  saturated  with  hot  water  and  bearing  a  temperature  of 
140°  Fahr. ,  for  instance,  be  applied  to  an  inflamed  knee,  the  heat 
rays  will  radiate  from  the  heated  substance  to  the  knee  until  both  knee 
and  cloth  attain  nearly,  if  not  quite,  a  mean  and  uniform  temperature. 
A  similar,  though  reversed,  action  takes  place  when  a  cloth  saturated  with 
water  at  40°  Fahr.  is  applied  in  the  same  manner.  The  heat  of  the 
knee  in  this  case  being  far  in  excess  of  that  of  the  applied  cloth,  the 
thermal  rays  are  at  once  set  into  outward  motion,  imparting  the  body  heat 
to  the  wet  cloth  until  both  knee  and  cloth  are  of  nearly  the  same  tempera- 
ture. This  extraction  of  heat  is  described  by  most  authors  as  the  applica- 
tion of  cold. 

The  application  and  extraction  of  heat  should  only  be  resorted  to  after 
an  intelligent  study  and  consideration  of  existing  conditions  in  each  indi- 
vidual case.  While  the  application  of  heat  is  not  likely  to  produce  a  harm- 

222 


APPLICATION    AND    EXTRACTION    OF     HEAT. 


223 


ful  effect,  its  extraction  might  be  followed  by  serious  consequences  in  some 
cases. 

Extraction  should  be  discontinued  when,  at  any  time,  it  tends  to  increase 
the  pain  or  cause  discomfort  to  the  patient.  The  statements  of  patients 
may  usually  be  accepted  as  a  warning  note  in  all  cases  when  the  surgeon 
is  making  applications  with  a  view  to  heat  extraction.  When  this  occurs 
their  use  should  be  discontinued,  and  in  many  instances  the  method  should 
be  replaced  by  heat  application. 

If  moist  applications  are  preferred,  hot  antiseptic  solutions  should 
supply  the  heat.  From  a  surgical  standpoint,  the  time-honored  poultice  of 
bread  and  milk,  flaxseed  meal,  elm  bark,  etc.,  as  usually  applied,  practically 
now  exists  only  in  history.  They  undoubtedly  furnished  culture  media 
for  the  propagation  of  innumerable  hosts  of  bacteria,  and  there  can  be  no 


Figure  404.    Murphy's  Metal  Hot  Water  Can. 

doubt  that  untold  numbers  of  patients  have  suffered  from  infection  through 
broken  skin  surfaces  by  the  use  of  these  applications. 

Appliances  for  the  extraction  of  body  heat  should,  as  far  as  possible, 
exert  a  continuous  and  uniform  action ;  otherwise,  the  spasmodic  contrac- 
tion and  relaxation,  alternating  one  with  the  other,  may  cause  sufficient 
irritation  of  the  capillaries  and  other  affected  vessels  to  increase  the  degree 
of  inflammation. 

As  the  same  means  are  frequently  employed  for  both  the  application 
and  extraction  of  heat,  no  attempt  will  be  made  to  further  classify  them. 
The  various  appliances  in  use  for  these  purposes  consist  of  hot-water  bottles 
and  cans,  hot  fomentations,  poultices,  ice  bags,  ice  caps,  irrigation,  baths, 
etc. 

Hot  "Water  Bottles  and  Cans. 

Heat,  through  either  a  dry  or  moist  medium,  may  be  applied  by  means 
of  rubber  water-bottles  or  metal  cans.  These  may  be  employed  to  impart 
heat  directly  to  the  skin  or  to  supply  heat  to  fomentations,  poultices, 
etc. 

The  Plain  Soft  Rubber  Water  Bottle,  as  defined  in  figure  401,  is  an  appli- 
ance with  which  all  are  familiar.  When  properly  constructed  it  is  man- 
ufactured from  white  rubber,  and  supplied  with  a  loop  at  the  upper  end  for 


224 


RESOLUTION    OF    INFLAMMATION. 


carrying  or  handling-,  and  a  small  ring  at  the  lower  end  by  which  the  bag, 
when  not  in  use,  may  be  suspended  from  a  nail  or  hook  in  a  reversed  posi- 
tion. The  opening  in  the  bottle  should  be  sufficiently  large  to  admit  the 
nozzle  of  an  ordinary  faucet,  that  the  bag  may  be  filled  without  wetting  its 
outer  surface.  When  constructed  from  good  material  it  will  withstand 
the  action  of  boiling  water  for  a  long  continued  period. 

The  Soft  Rubber  Water  Bottle,  for  application  to  the  throat  and  neck, 
as  pictured  in  figure  402,  consists  of  a  crescent-shaped  bag,  the  inner  sur- 
face of  which  is  intended  to  envelop  the  front  and  sides  of  the  neck.  As 
it  is  small  and  somewhat  light  in  construction,  it  can  frequently  be 
borne  by  patients  who  might  object  to  the  weight  of  the  ordinary  forms  of 
water  bottles.  It  is  held  in  place  by  a  suitable  band  passing  around  the 
neck. 

Murphy's  Metal  Hot  Water  Can,  as  illustrated  in  figure  404,  is  called  by 
its  inventor  a  foot  and  bed  warmer.  It  is  constructed  wholly  of  metal,  and 
of  such  forms  and  curves  as  will  enable  it  to  rest  securely  in  an  upright 


position.  It  is  not  only  applicable  as  a  foot  warmer,  but  as  a  means  of 
conveying  heat  to  almost  any  portion  of  the  body.  The  outer  surface  is 
convex  and  the  inner  concave.  It  is  so  shaped  that  it  will  support  the 
weight  of  the  bedding,  and  this,  when  the  can  is  in  use  as  a  foot  warmer, 
is  of  great  advantage.  It  is  frequently  manufactured  from  brass  and 
nickel-plated.  It  is  usually  provided  with  a  soft  cover  of  canton  flan- 
nel, thus  modifying  the  imparted  heat.  This  cover  may  be  constructed 
with  an  apron  or  flap,  thus  retaining  the  warmth  for  a  longer  period. 

Hot  Fomentations. 

Hot  fomentations  usually  consist  of  cloths  saturated  with  hot  antiseptic 
solutions.  They  are  often  impregnated  with  a  germicidal  fluid,  more  as  a 
prophylactic  than  as  a  sterilizing  measure.  They  may  be  applied  directly 
to  the  skin,  and  that  they  may  retain  the  heat  as  long  as  possible,  they 
should  be  covered  with  some  form  of  water-proof  protective. 

Poultices  are  now  seldom  employed  in  the  treatment  of  inflammation. 
They  should,  under  no  circumstances,  be  applied  to  an  open  wound. 
Being  composed  of  vegetable  substances  and  maintained  at  or  above  the 


HOT    FOMENTATIONS. 


225 


normal  heat  of  the  body,  rapid  decomposition  ensues  until  they  become  a 
veritable  hot-bed  for  the  development  of  bacteria.  If  applied  for  too  great 
a  length  of  time,  even  over  an  intact  skin,  maceration  will  ensue  and  infec- 
tion result. 

Hemsteger's  Compress  Protector,  as  pictured  in  figure  403,  will  be  found 
useful  in  every  household. 

While  almost  any  form  of  water-proof  material  will  answer  as  a  cover- 
ing for  hot  fomentations,  this  is,  perhaps,  more  satisfactory  than  any 
improvised  covering  that  the  surgeon  might  construct.  It  consists  of  a 
soft  rubber  shield  wholly  covering  the  outer  side  of  a  compress,  and  so 
shaped  at  its  margins  as  to  bind  and  hold  in  position  the  outer  edges  of 


Figure  406.     Helmet  Ice  Cap. 


Figure  407.    Baird's  Compress  Heater. 


the  saturated  cloths.  It  is  in  reality  a  bag  with  the  central  part  on  one 
side  cut  away,  leaving  enough  of  the  border  of  that  side  to  hold  the  con- 
tained cloths.  Suitable  loops  permit  the  binding  of  the  compress  cover  in 
position,  so  that  accidental  misplacements  are  not  likely  to  occur.  It  is 
useful,  as  it  retains  the  heat  or  moisture  for  a  considerable  length  of  time, 
thus  obviating  the  necessity  of  frequent  changes.  It  protects  the  patient 
from  the  dripping  that  might  issue  from  the  edges  of  a  cloth  compress,  and 
permits  more  or  less  movement  of  the  patient  without  danger  of  misplace- 
ment. It  may  also  be  employed  for  retaining  compresses  in  place,  for 
which  use  it  answers  an  admirable  purpose. 

Baird's  Compress  Heater,  shown  in  figure  407  and  called  by  its  inventor 
a  steam  fomentor,  is  a  small  steam  generator  connected  by  hose  with  a 
rubber  coil.  By  placing  the  coil  within  a  compress  or  in  contact  with 
a.  poultice,  either  may  be  heated  to  and  maintained  at  any  desired 
temperature.  As  it  furnishes  a  continuous  heated  application  and  con- 
ducting medium,  it  does  not  require  changing  as  is  the  case  when  cloths 
saturated  with  hot  water  or  common  poultices  are  employed.  This  obvi- 
ates the  dangers  incurred  by  the  frequent  changes  in  temperature  incident 
to  the  removal  and  reapplication  of  ordinary  compresses.  The  apparatus 
may  be  employed  for  the  application  of  dry  heat,  and  as  such  will  be  found 

15 


226 


RESOLUTION    OF    INFLAMMATION. 


valuable  in  treating  many  cases  of  inflammation.  Attachments  can  also  be 
added  by  which  it  may  be  used  as  a  vapor  bath  for  steam  inhalation  and  for 
heating-  foods  in  the  sick  room. 

Ice  Bags,  Caps,  Etc. 

Bags  or  containers  for  the  application  of  ice,  with  which  to  reduce  the 
temperature  of  a  part,  may  be  obtained  in  various  forms.  In  order  to 
avoid  actual  freezing  of  the  skin  surface  and  underlying  tissues  by  the 
application  of  containers  filled  with  broken  ice  or  compounds  to  induce 
freezing,  the  affected  part  should  first  be  covered  with  one  or  more  thick- 
nesses of  cloth,  that  it  may  be  properly  protected  from  such  injury. 

The  German  Ice  Bag,  a  likeness  of  which  may  be  seen  in  figure  405,  is 
constructed  of  rubber-covered  cloth,  soft  and  pliable,  the  cloth  gathered 
into  a  water-tight  neck  surmounted  by  a  close-fitting  metal  cap.  The 
opening  into  the  bag  is  of  sufficient  size  to  admit  the  free  introduction  of 
small  pieces  of  ice. 

The  Helmet  Ice  Cap,  as  shown  in  figure  406,  exhibits  a  special  form  of 
ice  receptacle,  constructed  with  a  view  to  surrounding  the  upper  portion  of 


Figure  408.    Spinal 
Ice  Bag. 


Figure  409.    Plain  Ice  Bags. 


Figure  410.     Bishop's  Mastoid  Ice  Bag. 


the  head  with  a  container  that  may  be  filled  with  broken  ice.  The  adjust- 
ment of  the  neck  of  this  apparatus  should  be  water-tight,  that  leakage  may 
not  occur.  It  is  usually  to  be  found  in  two  sizes,  medium  and  large. 

The  Spinal  Ice  Bag,  disclosed  by  figure  408,  represents  a  slender  form 
of  bag  suitable  for  applications  to  the  throat  or  spine.  It  should  be 
made  from  pure  rubber.  After  having  been  filled  with  small  pieces  of  ice, 
the  open  end  may  be  folded  or  rolled  upon  itself,  and  fastened  with  a  cord 
or  band. 

The  Plain  Ice  Bags,  illustrated  in  figure  409,  consist  of  plain  bottle- 
shaped  appliances  provided  with  extra  wide  mouths,  each  composed  of 
a  single  piece  of  pliable  soft  rubber.  They  may  be  procured  in  various 
sizes.  Their  principal  advantage  consists  in  their  low  price,  for  it  is  some- 
what difficult  to  prevent  the  water,  as  it  accumulates  from  the  melting  ice, 
from  being  spilled  upon  clothing  or  bedding. 

Bishop's  Mastoid  Ice  Bag,  as  portrayed  in  figure  410,  consists  of  a  small 
crescentic  bag  with  a  large  mouth,  so  arranged  that  it  may  be  filled  with 
cracked  ice  and  used  for  the  extraction  of  heat  in  diseases  of  the  ear.  The 
concave  margins  of  the  bag  may  be  placed  back  of  and  against  the  ear, 


IRRIGATION     APPARATUS. 


227 


where  it  may  be  retained  in  place  by  tapes  attached  to  several  loops  that 
form  a  portion,  of  the  outer  margin.  A  tight-fitting  rubber  cap  extending 
over  the  upper  margin  of  the  neck  forms  a  water-tight  joint. 

Irrigation  Apparatua 

The  benefit  of  irrigation,  whether  hot  or  cold,  may  be  secured  by  two 
methods,  immediate  and  mediate.  The  former  consists  in  bringing  a  flow 
of  water  in  direct  contact  with  the  inflamed  parts. 

The  Apparatus  for  Immediate  Irrigation,  shown  in  figure  413,  comprises  a 
reservoir,  hose,  cut-off,  and  irrigating  frame,  by  which  a  continuous  flow 
of  water,  either  plain  or  medicated,  may  be  brought  in  direct  contact 


Figure  412.     Water  Coil  for  the  Head. 


Figure  413.     Irrigating  Siphon. 


with  any  portion  of  the  body.  In  the  absence  of  a  reservoir,  a  suspended 
pail  or  other  vessel,  or  a  pitcher  resting  upon  a  shelf  or  other  elevation, 
may  be  made  to  answer  every  purpose.  Facilities  for  drainage  may  be 
improvised  by  the  surgeon.  In  the  absence  of  a  proper  stop-cock,  a  wooden 
plug  or  cork,  with  a  small  slot  cut  in  one  side,  may  be  used  to  occlude  the 
rubber  hose,  thus  obtaining  perfect  control  of  the  flow. 

A  Simple  Apparatus  for  immediate  Irrigation  may  be  improvised  by  tak- 
ing some  form  of  open-mouthed  bottle,  into  the  neck  of  which  and  extend- 
ing nearly  or  quite  to  the  bottom,  is  inserted  a  skein  of  thread,  lamp  wick, 
gauze  or  similar  material ;  this  is  allowed  to  extend  over  the  side  of  the 
bottle,  reaching  to  a  point  a  short  distance  below  the  bottom  of  the  latter. 
This  will  act  as  a  capillary  siphon,  by  means  of  which  a  flow  of  water  may 
be  obtained  that  will  fall,  drop  by  drop,  upon  any  directed  point. 


228 


RESOLUTION    OF    INFLAMMATION. 


Mediate  Irrigation  consists  in  the  passage  of  hot  or  cold  fluids 
through  coiled  tubes  placed  against  or  around  the  surface  of  the  inflamed 
parts.  These  tubes  may  be  composed  of  metal  or  soft  rubber  hose,  the 
latter  being  preferred.  They  may  be  employed  for  either  the  application 
or  extraction  of  heat. 

The  Soft  Rubber  Water  Coil,  exhibited  in  figure  411,  consists  of  a  contin- 
uous piece  of  soft  rubber  hose  wound  in  a  spiral  form,  the  various  coils 
being  held  in  position  by  soft  rubber  lateral  bands.  By  attaching  one  of 


Figure  414.    Burr's  Portable  Bath  Frame. 

the  free  ends  of  the  coil  to  a  hose  connected  with  a  reservoir,  a  continuous 
flow  of  hot  or  cold  fluid  may  be  procured.  They  may  be  purchased  5,  7,  9, 
ii  or  13  inches  in  diameter. 

The  Soft  Rubber  Head  Coil,  represented  in  figure  412,  is  a  similarly 
constructed  coil  designed  for  making  applications  to  the  upper  portion  of 
the  head.  They  are  usually  of  two  sizes,  4  and  5  inches  in  height  respec- 
tively with  a  diameter  of  7  inches. 

Bath  Apparatus. 

The  most  rapid  and  complete  method  of  imparting  or  withdrawing  heat 
from  the  body  is  by  baths,  and  that  this  may  be  accomplished  at  the  bed- 
side, portable  forms  of  bathing  apparatus  have  been  devised.  Several 
patterns  manufactured  from  metal  will  be  found  described  by  figures  147 
and  148. 

Burr's  Portable  Bath  Frame,  as  displayed  in  figures  414  and  415,  consists 
of  a  light  folding  wooden  crib  lined  with  a  water-tight  rubber  sheet,  the 
whole  forming  a  tub  of  sufficient  size  to  permit  a  patient  to  be  bathed  while 


Figure  415.    Burr's  Bath  Tub  Complete,  showing  Siphon  for  Drawing  Off  the  Water. 

in  bed  and  to  secure  partial  or  complete  immersion.  The  rubber  sheet  is 
first  placed  beneath  the  patient  and  closely  folded  around  him,  the  frame 
placed  in  position,  the  sheet  securely  attached  to  the  frame  by  suitable  rings, 
after  which  the  tub  may  be  filled  with  water  to  the  extent  desired. 

The  water  may  be  removed  from  the  tub  by  the  exercise  of  the  siphon 
principle,  a  piece  of  curved  metal  tube  and  rubber  hose  being  all  that  is 
necessary. 

When  patients  require  either  cold  or  hot  baths  and  are  not  in  a  condition 
to  be  removed  to  the  bath-room,  this  apparatus  is  of  great  advantage,  and 
one  or  more  should  form  a  portion  of  every  hospital  outfit. 


BLOOD-LETTING. 


229 


Knowlton's  Bath,  as  indicated  in  figure  416,  consists  of  a  soft  rubber 
water-proof  hammock  suspended  from  a  wooden  frame  of  narrow  bow 
shape.  As  the  sack  or  bag  may  be  folded  flat,  the  apparatus  when 
not  in  use  occupies  no  more  space  than  a  board  of  the  same  width  and 
length.  It  is  of  sufficient  length  for  the  use  of  an  adult  when  lying  down. 
By  means  of  a  cord  it  may  be  converted  into  a  small  bath  for  children,  a 


Figure  416.     Knowlton's  Portable  Bath. 

sitz  or  a  foot  bath,  as  'shown  in  the  figure.  The  ends  of  the  frame  are 
arranged  that  they  may  rest  upon  ordinary  chairs,  thus  safely  and  econom- 
ically suspending  the  apparatus.  It  is  comparatively  inexpensive,  and  can 
be  made  useful  in  cases  where  ordinary  baths  cannot  be  utilized. 


BLOOD-LETTING. 

This  consists  in  withdrawing  blood  from  the  circulation  by  mechanical 
methods.  It  may  be  accomplished  by  scarification,  leeching  or  venesection. 

Scarification. 

Scarification  consists  in  forming  numerous  small  superficial  openings  in 
the  overlying  tissues,  for  the  purpose  of  permitting  the  escape  from  below 
of  blood,  serum,  gas,  etc.  This  may  be  accomplished  by  incisions  and  punc- 
tures, with  or  without  cupping. 


Figure  417.     Plain  Thumb  Lance. 


Figure  418.    Twelve-Blade  Scarlficator. 


Either  of  these  procedures  may  be  supplemented  by  the  use  of  cupping, 
the  combination  forming  an  operation  known  as  "wet  cupping, "  or  cupping 
that  withdraws  blood.  The  appliances  necessary  for  cupping  will  be 
described  in  connection  with  figures  425  to  428.  Scarification  by  incision 
may  be  secured  with  a  scalpel,  sharp-pointed  bistoury,  or  special  lancets. 
In  former  years  this  operation  was  performed  with  an  instrument  called  a 
scarificator. 


230 


RESOLUTION    OF    INFLAMMATION. 


The  Scarificator  indicated  in  figure  418  consists  of  a  number  of  small 
blades  so  constructed  as  to  be  operated  by  a  powerful  spring.  The  cutting 
edges  of  the  knives  are  circular  in  form,  and  are  all  designed  to  cut  to  the 
same  depth,  the  extent  of  which  may  be  regulated  b>;  a  screw  device.  By 
setting  and  releasing  the  spring,  the  incisions  are  made  so  quickly  as  to 
produce  no  pain.  This  instrument  being  automatic,  complicated  and  diffi- 
cult to  clean,  is  now  but  little  used.  It  has  been  replaced  by  the  scalpel 
and  bistoury,  which  are  more  completely  under  the  control  of  the  surgeon. 

Buttle's  Scarificator,  as  set  forth  in  figure  419,  though  designed  expressly 
for  scarifying  the  cervix,  may  be  used  as  a  general  Scarificator.  It  consists 
of  a  small  lance-shaped  needle  attached  to  a  metallic  handle.  A  small  cap, 
adjusted  so  as  to  enclose  the  needle  and  fit  tightly  to  the  handle,  protects 
it  from  becoming  damaged  when  not  in  use. 

Byford's  Scarificator,  as  it  appears  in  figure  420,  is  an  improved  form, 
designed  particularly  for  uterine  work. 

In  construction  it  is  similar  to  the  one  last  described,  differing  only  in 
the  shape  of  the  blade,  which  in  this  instance  is  shaped  like  a  trocar;  that 


Figure  419.     Buttle's  Scarificator. 


is,  it  is  provided  with  three  cutting  edges,  the  space  between  each  pair  of 
edges  being  concave.  The  point  is  exceedingly  sharp  and  the  instrument 
most  effective.  It  produces  a  puncture  not  likely  to  close  or  heal  by  first 
intention,  as  is  often  the  case  after  a  simple  incision. 

Scarification  by  Puncture  consists  in  perforating  the  skin  with  needles  or 
needle-shaped  instruments.  It  may  be  accomplished  by  making  many 
strokes  with  a  single  needle,  or  including  a  number  of  needles  in  a  single 
appliance.  An  instrument  known  as  the  "Lebenswecker"  has  been  used 
in  Germany  for  many  years  for  this  purpose.  As  it  is  employed  more  par- 
ticularly for  counter-irritation,  it  will  be  described  under  that  head. 

Leeching  consists  in  the  application  of  a  leech,  either  natural  or  artificial, 
that,  by  its  drawing  or  sucking  powers,  it  may  extract  a  given  quantity  of 
blood.  Live  leeches  are  usually  of  two  varieties,  American  and  Swedish. 
The  former  withdraws  at  a  single  application  about  one  teaspoonful  of 


Figure  420.    Byford's  Scarificator  with  Trocar  Point. 

blood,  the  latter  from  three  to  four  teaspoonfuls.  Owing  to  the  danger  of 
infection  from  live  leeches,  their  use  has  been  gradually  abandoned,  until 
at  the  present  time  they  are  seldom  employed.  Because  of  the  irritation 
produced  by  their  action,  they  are  usually  not  applied  directly  to  the  inflamed 
surface,  but  to  the  tissues  immediately  adjacent.  As  hemorrhage  fre- 
quently follows  their  use,  they  are  ordinarily  applied  in  the  morning,  that 
the  after-effects  may  be  more  closely  watched.  If  on  application  they  fail 
to  take  hold  actively,  they  may  be  induced  to  begin  operations  by  drawing 
a  drop  of  blood  from  the  prick  of  a  needle,  or  applying  warm  cream  to  the 
surface.  Once  attached  they  should  never  be  forcibly  removed,  but  allowed 
to  release  their  hold  of  their  own  accord.  Their  movements  should  be 
confined,  and  for  this  reason  it  is  customary  to  enclose  them  under  the 
open  end  of  a  test  tube,  wineglass  or  similar  article.  If,  after  their 
removal,  bleeding  continues,  it  may  be  arrested  by  pressure,  by  the  appli- 


BLOOD-LETTING.  231 

cation  of  a  gauze  compress,  hot  fomentations  or  styptics,  and  where  these 
fail,  by  the  excision  of  the  opening  or  bitten  portion.  This  latter  procedure 
is  sometimes  necessary  because  a  live  leech  conveys  to  its  self-made  wound 
a  secretion  that  successfully  prevents  coagulation  at  the  wound  opening. 

Artificial  Leeches. 

An  artificial  leech  consists  of  a  small  and  somewhat  slender  form  of  cup 
and  exhaust  pump  or  syringe,  used  for  drawing  blood  from  one  or  more 
incisions.  These  may  have  been  previously  made  with  a  scalpel  or  bis- 
toury, or  they  may  be  cut  by  a  special  lancet  operated  by  a  spring,  the 
whole  contained  within  the  cup. 

Heurteloup's  Leech,  as  outlined  in  figure  421,  consists  of  a  glass  cylinder 
open  at  the  lower  end,  the  upper  being  surmounted  by  a  metal  cap.  A 
piston  works  within  the  cylinder  something  after  the  principle  of  an  ordi- 


Figure  431.     Heurteloup's  Leech. 


nary  syringe,  excepting  that  the  packing  of  the  piston  is  constructed  to 
work  closely  within  the  chamber.  The  piston  rod  is  in  the  form  of  a 
threaded  screw,  constructed  in  such  a  manner  that  the  withdrawal  of  the 
piston  may  be  accomplished  by  screw  power. 

Thomas'  Artificial  Leech,  as  illustrated  in  figure  422,  is  an  instrument 
designed  expressly  for  cupping  the  cervix.  It  consists  of  a  long  and  some- 
what slender  hard  rubber  cylinder,  enclosing  a  suitable  piston  with  rod  and 
thumb  ring.  The  piston  is  supplied  with  a  leather  packing  fitted  so  as  to 
exert  sufficient  pressure  that  the  withdrawal  of  the  former  will  produce  a 
vacuum.  It  may  be  used  for  wet  cupping  following  scarification,  or  for 
the  ordinary  dry  cupping. 


Figure  422.    Thomas'  Artificial  Leech. 

Flood's  Artificial  Leech,  as  sketched  in  figure  423,  is  composed  of  a 
single  piece  of  glass.  It  is  intended,  like  the  one  before  mentioned,  for 
uterine  application.  It  is  operated  by  being  attached  to  some  form  of 
exhaust  pump.  It  may  be  used  to  special  advantage  when  attached  to  the 
author's  surgical  pump  described  on  page  203.  Its  advantage  consists  in  its 
employment  as  a  wet  cupper,  because,  as  it  is  composed  of  glass,  the 
quantity  of  blood  withdrawn  may  be  easily  noted.  An  enlargement  upon 
the  under  side  of  the  cylinder  and  located  near  the  proximal  end  acts  as 
a  reservoir  for  the  blood,  that  it  may  not  enter  and  pass  through  the  pump- 
ing apparatus. 

Recce's  Artificial  Leech,  as  shown  in  figure  424,  is  constructed  somewhat 
on  the  principle  of  the  two  appliances  just  described,  but  in  addition  it  is 
provided  with  a  lancet  that  passes  directly  through  the  center  of  the  piston 
and  plunger.  This  lancet  is  controlled  by  a  spring  and  threaded  screw  in 


232 


RESOLUTION    OF    INFLAMMATION. 


such  a  manner  that  the  perforation  may  be  made  after  or  during  the  ex- 
haustion of  the  air.  As  the  cylinder  is  graduated,  the  amount  of  blood 
extracted  may  be  noted  from  time  to  time. 

Venesection. 

Venesection  consists  in  opening  a  vein  for  the  purpose  of  permitting  the 
escape  of  blood.  This  operation,  once  quite  popular,  is  now  seldom  em- 
ployed, and  the  reign  of  the  lancet  practically  exists  only  in  history.  The 
operation  may  be  performed  either  with  a  plain  thumb  lancet  or  a  spring 
lancet,  the  former  being  preferred. 


Figure  423.    Flood's  Artificial  Leech. 


The  Plain  Thumb  Lancet,  portrayed  in  figure  417,  consists  of  a  short, 
thin,  double-edged  blade,  both  sides  being  sharpened  to  the  point.  Vene- 
section was  performed  for  many  years  with  a  spring  lancet,  an  instrument 
constructed  in  such  a  manner  that  a  lance-shaped  point,  under  the  pressure 
of  a  strong  spring,  could  be  quickly  driven  into  a  vein,  thus  performing 
the  operation  practically  without  producing,  or  with  only  momentary,  pain. 
It  is  now  seldom,  if  ever,  used. 


DRY   CUPPING. 

This  consists  in  the  application  of  a  cup-shaped  instrument  with  smooth, 
even  margins,  so  arranged  that  the  contained  air  may  be  partially  or  wholly 
exhausted  and  a  vacuum  formed.  It  is  employed  as  a  means  of  accomplish- 
ing local  depletion  by  drawing  the  blood  from  the  deeper  parts  to  the  sur- 


Figure  424.     Recce's  Artificial  Leech. 


face  of  the  skin.  Cupping  may  be  either  dry  or  wet.  The  latter  procedure 
has  been  already  described  under  scarification.  Dry  cupping  requires  no 
incision,  the  cup  being  simply  applied  to  the  surface  and  the  air  exhausted. 
This  accomplishes  both  counter-irritation  and  depletion.  Owing  to  the  pain 
produced  by  the  suction  of  the  cup,  it  should  never  be  applied  directly  over 
an  inflamed  surface.  Ordinarily,  a  cup  should  be  allowed  to  remain  in 
place  from  thirty  to  forty-five  minutes. 

The  Plain  Cupping  Glass,  as  defined  by  figure  425,  is  constructed  in  the 
form  of  a  tumbler,  excepting  that  it  is  provided  with  a  dome-shaped  top. 
Cupping  glasses  of  this  character  are  applied  by  burning  in  the  interior  of 
the  glass  a  small  quantity  of  alcohol  or  paper,  thus  expanding  the  con- 
tained air,  during  which  time  the  cup  must  be  quickly  placed  in  position. 
A  little  experience  will  enable  the  operator  to  perform  this  operation  with- 
out difficulty. 


COUNTER-IRRITATION  233 

Instruments  of  similar  form,  particularly  for  army  use,  are  frequently 
manufactured  from  metal. 

The  Rubber  and  Glass  Cupper,  shown  in  figure  426,  is  composed  of  a 
glass  cup  surmounted  by  a  soft  rubber  bulb.  To  apply  this  cup  it  is 
necessary  only  to  indent  or  evert  the  rubber  bulb  by  pressure  with  the 
thumb  or  finger,  applying  the  cup  while  the  bulb  is  thus  compressed.  Upon 
being  released,  the  tendency  of  the  bulb  to  regain  its  normal  shape  rarefies 


Figure  425.    Plain  Glass  Cupper.  Figure  420.    Rubber  Bulb  Cupper. 

or  expands  the  air  contained  in  the  cup,  thus  producing  sufficient  force  for 
the  purpose. 

Parker's  Cups,  as  pictured  in  figure  427,  consist  of  a  series  of  metal 
cups,  varying  from  2  to  5  inches  in  diameter.  A  valve  and  tube  are  supplied, 
by  means  of  which  they  may  be  connected  with  a  small  upright  exhaust 
pump  that  is  arranged  for  use  by  placing  the  foot  piece  under  an  ordinary 
chair  lee. 


COUNTER-IRRITATION. 

Counter-irritants  are  substances  or  means  employed  to  excite  external 
irritation.  The  extent  of  their  action  varies  according  to  the  materials  or 
methods  used  and  duration  of  application.  Counter-irritation,  although 
once  quite  popular,  is  now  seldom  employed.  The  methods  in  vogue  are 
the  seton,  mechanical  cautery  and  vesicating  puncture. 

Seton. 

The  seton  is  a  subcutaneous,  suppurative  artificial  wound  maintained  by 
the  presence  of  a  foreign  body.  It  may  be  formed  with  a  bistoury  or  a 
scalpel  and  a  piece  of  rubber  band,  strip  of  muslin,  or  a  few  strands  of 
thread.  The  foreign  body  may  be  conveyed  beneath  the  skin  by  means  of 
a  probe  with  an  eye,  or  a  special  needle  constructed  for  the  purpose. 

Mechanical  Cautery. 

This  method  of  counter-irritation  may  be  accomplished  by  bringing  in 
contact  with  the  skin  some  metallic  substance  that  has  previously  been 
brought  to  a  red  heat.  Care  should  be  taken  in  the  application  of  the  cautery 
to  destroy  only  the  cuticle  and  papilla  tips,  as  this  will  avoid  the  cicatrical 
contraction  in  healing.  The  various  forms  of  cauteries  are  illustrated 
on  pages  218  and  219. 


234 


RESOLUTION    OF    INFLAMMATION. 


Puncture— Simple  or  Vesicating1. 

Baumscheidt's  Lebenswecker,  as  illustrated  in  figure  429,  consists  of  a 
wooden  or  rubber  cylinder  terminating  in  a  hollow  handle.    Within  the  cylin- 


Figure  427.    Parker's  Cups. 


Figure  428.     Parker's  Cupping 
Pump. 


der  is  a  piston  controlled  by  a  spiral  metallic  spring.  The  piston  is  armed 
with  numerous  small  needles,  so  arranged  that  by  pulling  upon  the  handle 
and  thus  pressing  the  spring,  the  needles  will  be  driven  a  short  distance 
into  the  skin  as  soon  as  the  spring  is  released.  .  The  extent  of  counter- 
irritation  produced  may  be  largely  increased  by  dipping  the  points  of  the 


Figure  429.    Baumscheidt's  Lebenswecker. 

needles  before  using  into  a  mixture  consisting  of  equal  parts  of  croton  and 
olive  oils.  Numerous  small  vesicles  will  follow  the  application,  usually 
within  twenty-four  hours.  Owing  to  the  difficulty  in  rendering  this  instru- 
ment surgically  clean,  it  is  now  seldom  employed  in  this  country. 

IGNIPUNCTURE. 

Ignipuncture  consists  in  perforating  the  sk-in  or  other  inflamed  parts 
with  heated  needles.  Ordinary  needles  at  a  red  heat  may  be  employed,  or 
the  surgeon  may  make  use  of  a  thermo-cautery  provided  with  a  sufficiently 
fine  point. 

PARENCHYMATOUS  INJECTIONS. 

The  parenchymatous  treatment  of  inflammation  consists  in  injecting  or 
infusing  into  the  inflamed  tissues  certain  germicidal  solutions.  This 
method  is  applicable  in  the  early  stages  of  inflammation,  where  only  limited 
areas  of  tissues  are  involved.  These  injections  may  be  accomplished  by 
such  apparatus  as  Senn's  injection  syringe,  see  figure  387;  Heuter's  infuser, 
see  figure  388 ;  or  a  hypodermic  syringe  of  large  size,  see  figure  368. 

Care  should  be  exercised  not  to  administer  a  toxic  dose  of  the  remedy 
employed.  The  total  amount  injected  should  not  exceed  the  quantity  that 
might,  with  safety,  be  administered  internally. 


CHAPTER  XVI. 


ELECTRO-THERAPEUTICS. 

The  forms  of  electric  currents  or  electric  manifestations  of  value  in 
electro-therapeutics  and  electro-surgery  may  be  classified  as  the  direct 
primary  current  or  galvanism;  the  induced  current  or  faradism ;  the 
direct  current  dynamo:  the  indirect  current  dynamo;  galvano-cautery ;  the 
static  current  or  Franklinism,  and  X-ray  or  skiagraphic. 


THE  DIRECT  CURRENT  OR  GALVANISM. 

The  current  in  electro-therapeutics  now  known  as  the  "direct,"  was  for 
many  years  referred  to  as  the  galvanic,  constant,  or  continuous.  It  is  a 
current  of  voltage  or  pressure,  and  when  generated  by  chemical  action, 
depends  not  only  on  the  size  but  on  the  number  of  the  cells  forming  the 


B 


Figure  430.     Showing  Section  of  a  Direct  Current  Primary  Battery  with  a  Pair  of  Elements  and  Other 
Connections  for  Use  with  Bichromate  Solutions. 


Conne 

battery  or  series.  It  is  called  the  "direct"  current  because  it  flows  in  one 
direction  only,  from  the  positive  to  the  negative.  It  is  electrolytic,  cata- 
phoretic  and  electro-chemical  caustic  in  its  action. 

Of  the  various  forms  of  one-direction  currents,  those  employed  in  the 
treatment  of  disease  are  usually  obtained  from  either  a  primary  battery  (a 
self-generating  battery)  or  a  direct  current  dynamo  (a  commercial  current). 
The  "first  mentioned  is'  generally  employed.  A  third  method,  a  secondary 
battery,  or  one  of  storage  cells,  may  be  utilized,  but  not  to  advantage. 

235 


236 


ELECTRO- THERAPEUTICS. 


Primary  Batteries. 


These  are  of  two  varieties,  those  with  single  fluid  cells  and  double  fluid 
or  constant  cells. 

Single  Fluid  Cells  are  of  many  patterns,  among  which  are  the  zinc 
carbon,  many  of  the  so-called  dry  cells,  Leclanche,  persulphate  of  mer- 
cury, etc. 

The  zinc-carbon  cells  are  more  largely  employed  for  portable  direct 
current  batteries  than  any  other  form.  The  exciting  fluid  is  a  solution  of 
bichromate  of  potash  or  soda  and  sulphuric  acid,  the  positive  element  be- 
ing a  plate  of  zinc ;  the  negative,  one  or  two  plates  of  carbon. 

Recent  developments  would  seem  to  indicate  that  bichromate  of  soda 
makes  a  stronger  and  better  fluid  than  the  similar  preparation  of  potash. 
Further,  it  has  been  shown  that  by  its  use  the  cells  are  kept  free  from  the 
annoying  deposit  of  chrome-alum  crystals.  These  cells  for  therapeutic  use 
furnish  the  current  formerly  known  as  the  galvanic,  or  continuous,  but  now, 
as  above  indicated,  called  the  "direct."  Batteries  of  this  type  are  numer- 
ous, and  usually  include  from  8  to  36  cells  in  one  series. 

Hyslop's  Direct  Current  Battery  Cell,  as  shown  by  figure  430,  illustrates 
one  of  the  latest  forms  in  use.  The  zinc  and  carbon  in  this  set  of  elements 
are  connected  by  a  single  piece  of  heavy  metal,  so  shaped  as  to  clamp  the 


A 

Figure  431.    Mclntosh's  Cells  in  Series  of  Six. 

elements  firmly,  effectually  preventing  lateral  or  rotary  displacement. 
The  upper  portion  of  each  pair  is  thickly  coated  with  paraffin,  that  the 
metallic  connections  may  be  thoroughly  protected  from  the  corrosive  action 
of  the  acid. 

The  cells  are  single,  of  glass  and  with  ground  tops.  The  fluid  is 
retained  during  transportation  by  a  hydrostat  "D"  with  soft  rubber  face, 
the  latter  held  in  place  by  screw  rods  "E. "  By  means  of  an  emergency 
cord  "N,"  one  or  more  disabled  cells  may  be  taken  out  of  the  circuit  and 
the  efficiency  of  the  balance  of  the  battery  retained. 

By  means  of  knife-switches  the  patient  may  at  first  be  placed  in  a  circuit 
with  only  one  cell,  after  which  any  number  in  the  battery  may  be  added  by 
means  of  a  second  switch  without  producing  shock.  When  treatment  is 
discontinued,  all  but  one  may  be  taken  out  of  circuit,  after  which  this 
cell  may  be  removed  also  without  shock. 

The  Mclntosh  Direct  Current  Cell  is  well  exhibited  by  figure  431.  This  is 
perhaps  the  best  known  of  all  appliances  of  this  character.  "A"  shows  the 
hard  rubber  plate  of  a  section  (  on  the  under  surface  of  which  is  cemented 


PRIMARY    BATTERIES. 


237 


a  sheet  of  soft  rubber)  and  binding  posts,  which  project  through  the  hard 
and  soft  rubber  screwing  into  brass  pieces,  holding  the  zinc  and  carbon 
couples.  The  rubber  plate  on  which  the  couples  are  clamped,  projects  over 
on  one  side  enough  to  cover  the  cells  when  the  zinc  and  carbon  plates  are 
placed  in  the  drip-cups.  When  the  cells  are  not  in  use,  and  the  lid  of  the 
battery  box  is  closed,  it  presses  on  the  spring  handle  of  the  section  and  holds 
the  soft  rubber  firmly  over  the  cells  and  drip-cup. 

"B"  shows  a  section  of  six  cells  and  a  drip-cup  made  of  one  piece  of 
hard  vulcanized  rubber.  Any  number  of  these  sections,  each  comprising  a 
series  of  six  cells,  may  be  purchased  in  one  case. 

Dry  Cells  (so  called)  are  those  in  which  the  elements  are  carbon  or 
chloride  of  silver  and  zinc,  or  some  similar  combination.  Usually  in  cells 
of  this  form  the  exciting  fluid  is  absorbed  by  sponges,  bibulous  paper, 


Figure  432.    Chloride  of  Stiver  Dry  Cell. 


Figure  433.    Muriate  of  Ammonia  Dry  Cell. 


cornstarch,  or  a  similar  substance.  Owing  to  late  improvements  they  give 
off  little  or  no  gas,  so  that  they  may  be  hermetically  sealed.  They  are 
employed  both  for  direct  currents  and  induction  coils. 

The  Chloride  of  Silver  Dry  Cell,  as  shown  by  figure  432,  is  so  small  and 
light  when  compared  with  the  other  forms,  that  a  group  of  50  or  more  may 
be  arranged  to  form  one  battery  and  still  not  be  too  large  to  be  easilv 
transported.  The  size  of  the  cells  as  usually  manufactured  is  3^  inches  in 
height  by  if  inch  in  diameter.  Owing  to  the  more  limited  power  in  cells  of 
this  type,  it  is  necessary  to  use  a  larger  number  of  them  in  the  construction  of 
direct  current  batteries,  in  order  to  obtain  a  sufficient  pressure. 

Owing  to  improvements  in  attachments,  these  cells  may  at  all  times  be 
held  in  a  correct  position  and  proper  connections  insured. 

The  Muriate  of  Ammonia  Dry  Cell,  as  set  forth  in  figure  433,  known  as 
Falcon,  Imperial,  etc. ,  is  one  of  the  most  efficient  and  reliable  of  this  type. 
Generally  it  is  2^  inches  in  diameter  and  7  inches  in  height.  The 


238 


ELECTRO-THERAPEUTICS. 


outer  case  being  of  zinc  forms  the  positive,  while  a  flat  plate  of  carbon 
placed  within  the  case  and  projecting  at  the  top  forms  the  negative  ele- 
ment. A  sack  or  bag  containing  black  oxide  of  manganese  surrounds  the 
carbon  plate,  acting  so  as  to  reduce  polarization  and  increase  the  recupera- 
tive power  of  the  cell.  The  space  between  the  elements  is  filled  with  hard- 
wood sawdust,  which  absorbs  the  muriate  of  ammonia  solution.  The  cell, 
being  hermetically  sealed,  will  retain  moisture  indefinitely.  While  these 
cells  may  be  used  for  direct  current  batteries,  they  are  usually  employed 
for  surgical  use  only  in  the  construction  of  faradic  batteries  and  small 
electric  lights.  t 

The  Leclanche  Cell,  as  shown  by  figure  434,  is  largely  employed  for  office 
batteries.  Although  constructed  in  various  forms,  those  in  which  the 
negative  element  is  composed  of  a  single  piece  of  carbon  are  considered  the 
most  satisfactory. 

"A"  illustrates  a  cell  in  which  the  carbon  cylinder,  cover  of  jar  and 
connecting  parts  constitute  one  solid  piece  of  carbon.  This  entirely 


-f 


A  Figure  434.     Leclanch6  Cells.  B 

eliminates  the  possibility  of  corrosion.  The  zinc  rod  or  positive  element 
passes  through  the  carbon  cover,  from  which  it  is  insulated  by  a  porcelain 
sleeve.  The  upper  portions  of  the  carbon  and  the  glass  jar  are  coated  with 
paraffin,  as  this  serves  to  prevent  the  incrustation  of  solids  which  results 
from  capillary  attraction. 

"B"  illustrates  a  carbon  cylinder  cell  the  lower  part  of  which,  being 
cup-shaped,  is  filled  with  granular  black  oxide  of  manganese.  This  cup- 
shape  carbon  is  fastened  to  the  upper  portion  or  cover  by  means  of  a  screw 
thread  cast  in  each  section.  Corrosion  of  this  connection  is  possible,  but 
as  the  entire  upper  portion  of  this  element  is  well  coated  with  paraffin,  it 
rarely  occurs.  The  positive  element  of  this  cell  is  composed  of  sheet  zinc 
and  encircles  the  outer  surface  of  the  carbon  cup.  A  greater  surface  of 
zinc  is  exposed  to  the  action  of  the  exciting  fluid  in  this  cell  than  in  any 
other  of  the  Leclanche  type.  This  tends  to  increase  the  electro-motive  force 
or  pressure  of  current.  The  connecting  part  of  the  zinc  passes  through 
the  carbon  cover,  from  which  it  is  insulated  by  a  porcelain  sleeve  Rubber 
bands  surrounding  the  carbon  cup  prevent  the  elements  from  becoming 
short-circuited  internally.  A  muriate  of  ammonia  solution  is  used  in  all 
cells  of  the  Leclanche  type. 


PRIMARY    BATTERIES. 


239 


Double  Fluid  Cells,  sometimes  called  constant  cells,  are  those  in  which 
two  liquids  are  employed,  one  the  excitant,  the  other  the  depolarizer.  As 
cells  of  this  form  require  more  care  and  attention  than  the  single  fluid 
varieties,  they  are  seldom  employed  for  therapeutic  use.  While  several 
patterns  are  now  manufactured  we  will  confine  our  descriptions  to  a  single 
variety. 

Daniell's  Double  Fluid  Cell,  as  shown  by  figure  435,  consists  of  a  glass  jar 
containing  a  large  split  cylinder  of  copper,  within  which  a  porous  cup  is 
securely  fastened.  A  zinc  plate  immersed  in  dilute  sulphuric  acid  con- 
tained within  the  cup  furnishes  the  negative  pole.  The  positive  pole  is 
formed  by  the  copper  cylinder  when  immersed  in  a  saturated  solution  of 
copper  sulphate. 

The  Crowfoot  Gravity  Cell,  as  exhibited  in  figure  436,  is  an  improved  form 
of  the  Daniell  cell,  which  has  displaced  the  original  design.  It  has 
no  porous  cell  or  cup,  as  it  has  been  developed  by  experiments  that  the 
difference  in  specific  gravity  between  a  copper  and  zinc  solution  would 


Figure  435.     Daniell's  Double 
Fluid  Cell. 


Figure  436.     Crowfoot  Gravity  Cells. 


completely  separate  the  two  if  permitted  to  remain  quiet.  The  separating 
material  is,  therefore,  no  longer  necessary.  By  this  means  the  internal 
resistance  is  also  reduced,  which  is  a  marked  advantage. 

The  negative  element  of  this  cell  consists  of  thin  copper  in  strips  so 
riveted  together  that  it  will  remain  in  proper  position.  To  this  is  attached 
a  rubber  covered  wire  extending  out  of  the  jar.  This  wire  constitutes  the 
positive  pole.  The  positive  element  is  of  heavy  zinc  cast  in  the  form  of  a 
crow's  foot,  from  which  the  name  of  the  battery  is  derived. 

The  zinc  substance  is  constantly  lessened  by  being  transformed  into 
zinc  sulphate,  while  the  copper  plate  aggregates  by  deposition  on  the  yield- 
ing up  of  its  sulphuric  acid  by  the  copper  crystals. 

It  is  necessary  to  keep  the  cell  in  use,  as  otherwise  the  copper  solution 
will  rise  to  the  zinc,  there  being  no  action  when  the  circuit  is  open.  On  the 
other  hand  constant  use  will  develop  the  zinc  solution  in  excess  and  force 
down  the  copper  solution.  When  this  occurs  part  of  the  zinc  solution 
should  be  removed  and  the  jar  again  filled  with  water.  This  form  of  cell 
is  one  of  the  most  reliable  for  constant  use,  as  it  only  requires  material  in 
the  form  of  zinc  and  copper  sulphate  to  furnish  a  steady  current. 

Battery  Accessories. 

Among  the  many  accessories  advised  by  authorities  for  use  in  manipulat- 
ing electrical  ctirrents,  four  at  least  are  worthy  of  mention  here:  Milli- 
amperemeters,  rheostats,  rheotomes,  and  pole  changers. 


240 


ELECTRO-THERAPEUTICS. 


Milliamperemetera 


These  are  instruments  for  measuring  the  quantity  of  the  passing  electri- 
cal current.  They  consist  of  a  permanent  magnet  surrounded  by  a  coil  of 
insulated  wire.  The  passing  of  the  current  deflects  a  pivoted  needle  as 
regards  its  relation  with  the  magnet.  A  graduated  circle  is  subdivided  by 
spaces  and  figures  that  note  the  quantity  in  amperes  and  fractions  thereof. 

The  Standard  Milliamperemeter,  as  shown  in  figure  437,  is  one  of  the  most 
common  patterns  in  use.  Many  are  provided  with  two  scales  for  the 
administration  of  a  high  quantity  of  current,  one  being  graduated  from  o  to 
20,  the  first  five  divisions  being  measured  in  half  milliamperes,  the  other 
reading  from  o  to  1000  milliamperes  or  one  ampere. 

Rheostats. 

These,  as  now  constructed,  consist  of  devices  for  limiting  the  volume  of 
a  passing  current.  They  are  principally  employed  to  obtain  the  proper 
dosage  without  shock  to  the  patient. 

The  Jewell  Graphite  Rheostat,  as  illustrated  by  figure  438,  is  one  of  the 
most  reliable  instruments  for  this  purpose.  It  is  constructed  upon  the 


Figure  437.    Standard  Milliamperemeter. 

well-known  "shunt"  principle,  in  which  the  increase  and  decrease  of  current 
in  the  patient's  circuit  are  due  to  a  rise  and  fall  of  the  potential  on  the  line. 
It  therefore  is  more  properly  a  current  controller,  contact  being  obtained 
by  a  radial  arm  provided  with  spring  clips,  by  means  of  which  the  current 
is  directed  through  the  resisting  medium. 

Vetter's  Carbon  Rheostat,  as  exhibited  in  figure  439,  is  constructed  so  that 
the  current  is  caused  to  pass  through  a  mass  of  carbon  fragments.  These 
pieces  are  so  arranged  within  a  circular  chamber  that  they  may  be  com- 
pressed by  means  of  a  screw  and  plate,  somewhat  after  the  manner  of  an 
ordinary  letter-press.  By  turning  the  knob  "on"  or  "off,"  the  passing 
current  may  be  regulated  at  will. 

Eck's  Rheostat  Electrode,  as  portrayed  in  figure  440,  consists  of  a  metallic 
resistance  coil  arranged  in  piston  form  that  it  may  be  held  in  the  hand  of  the 
operator.  By  means  of  a  dial  and  marker  operated  by  a  thumb-piece,  the 
volume  of  a  direct  current  may  be  sustained  or  varied  at  will.  The 


RHEOSTATS,    RHEOTOMES. 


current  is  supplied  to  the  instrument  by  a  button  connection  placed  beneath 
the  apparatus.  A  metallic  disc  electrode  is  arranged  for  connection  with 
the  patient.  This  may  be  removed  and  a  sponge  or  any  other  form  of 
electrode  attached  in  its  place.  This  apparatus  furnishes  a  ready  and  con- 
venient means  for  regulating  the  amount  of  current  at  the  point  where  it  is 
brought  in  immediate  contact  with  the  patient. 

Liquid  or  Hydro-Rheostats  may  be  obtained  in  various  forms,  the  gen- 
eral plan  of  all  being  to  cause  the  current  to  pass  through  water  or  other 
liquid  for  a  sufficient  distance  to  properly  modify  its  strength. 

Bailey's  Hydro-Rheostat,  as  exhibited  by  figure  441,  consists  of  two 
triangular  carbon  plates,  each  hinged  along  one  side  and  controlled  by  a 
cog-wheel  mechanism  operated  by  a  thumb-screw.  These  plates  are 
mounted  on  the  rim  of  a  small  diamond-shaped  glass  dish,  the  two  being 
parallel,  but  about  half  an  inch  apart.  The  extremities  of  the  two  plates  are 
covered  with  sponges  in  order  to  furnish  a  good  contact  surface  when 
moist. 


Figure  4.38.    Jewell  Graphite  Rheostat. 


Figure  4;ii).     Vetter's  Carbon  Rheostat. 


By  filling  the  dish  nearly  full  of  water  and  turning  the  thumb- screw, 
the  carbons  may  be  gradually  immersed  in  the  fluid,  the  resistance  decreas- 
ing as  the  carbon  arms,  both  under  water,  approach  each  other.  This 
movement  allows  only  a  feeble  current  to  pass  at  first,  but  may  be  made  to 
supply  the  full  battery  force. 

Bheotomes. 

• 

These  are  sometimes  employed  for  interrupting  a  direct  current. 
Usually  they  may  be  regulated  for  slow  or  rapid  interruptions.  Like 
milliamperemeters  and  rheostats,  they  may  be  procured  separate,  or  may 
form  a  part  of  the  accessories  in  a  battery  plate. 

Mclntosh's  Automatic  Rheotome,  as  shown  by  figure  443,  is  arranged  for 
use  with  any  form  of  direct  or  faradic  current.  It  is  only  4^  by  7^  inches 
across  the  base  and  furnishes  a  durable  and  economical  instrument. 

The  Graduated  Automatic  Rheotome,  as  illustrated  by  figure  442,  differs 
from  the  one  previously  described  in  that  it  has  a  finer  adjustment  and  a 
stroke  more  easily  regulated.  It  supplies  any  number  of  interruptions,  from 
8  to  600  per  minute.  It  may  be  employed  with  any  form  of  direct  or 
induced  current  battery. 

16 


242 


ELECTRO-THERAPEUTICS. 


Pole  Changers. 

These  are  required  in  many  cases  to  change  the  direction  of  the  current 
through  the  cords.  They  usually  form  a  part  of  all  of  the  larger  portable 
batteries,  table  plates,  office  outfits,  etc. 

The  Pole  Changer,  as  shown  by  figure  444,  is  the  pattern  ordinarily 
employed.  It  consists  of  a  double  switch  so  wired  that  by  a  single  move- 
ment the  direction  of  that  portion  of  the  current  external  to  the  battery 
may  be  reversed. 


Figure  440.    Eck's  Rheostat  Electrode. 

Eck's  Pole  Changer,  as  shown  by  figure  445,  answers  the  double  purpose 
of  an  electrode  and  current  reverser.  A  small  disc  electrode  is  supplied 
with  each  instrument.  This  may  be  removed  and  replaced  by  any  other 
form  of  electrode  desired.  With  the  electrode  in  place,  the  direction  of 


Figure  441.     Bailey's  Hydro-Rheostat. 


Figure  442.    Mclntosh's  Graduated  Automatic 
Rheotome. 


the  current  may  be  instantly  changed  by  making  a  half  revolution  of  the 
handle.  This  arrangement  does  not  necessitate  the  use  of  a  pole  changer 
as  a  part  of  the  permanent  battery  outfit. 

Direct  current  batteries  require  more  or  less  care,  and  if  the  best  of 
results  are  to  be  obtained,  the  zincs  should  be  occasionally  amalgamated. 
From  use  the  zincs  become  encrusted  with  an  exudate  that  interferes  with 
the  chemical  action.  This  may  be  remedied  by  scraping,  washing,  and  then 


DIRECT    CURRENT    BATTERIES. 


243 


amalgamating  them.  The  latter  consists  of  a  coating  of  mercury.  This 
may  be  applied  by  dipping  the  zincs  in  dilute  muriatic  acid  and  then  either 
dipping  them  in  the  mercury  or  rubbing  them  with  a  separate  piece 
of  zinc  which  has  previously  been  amalgamated.  This  may  be  con- 
tinued until  the  zinc  elements  are  thoroughly  plated.  A  further  source  of 
trouble  is  a  deposit  of  chrome-alum  that  often  accumulates  in  the  bottoms 
of  the  cells.  This  may  be  removed  by  filling  the  cells  with  warm  water  and 
allowing  them  to  stand  for  several  hours,  after  which  the  deposit  may  be 
scraped  out  with  a  sharp  instrument. 

Hyslop's  Direct  Current  Battery,  as  illustrated  in  figure  446,  exhibits  one 
of  the  many  forms  in  which  direct  current  batteries  may  be  obtained. 

The  elements  employed   in   its  construction  are  shown  by  figure  430. 


Figure  443.     Mclntosh's  Plain  Automatic  Rheotome. 


Figure  444.     Pole  Changer. 


The  cells  are  single  and  of  glass  with  ground  tops  to  prevent  leakage.  A 
hydrostat  with  an  under  surface  of  soft  rubber  fits  closely  over  the  cell  tops. 
After  removing  the  hydrostat,  the  cells,  by  means  of  elevating  rods,  may 
be  raised  until  the  elements  are  immersed  in  the  contained  fluid.  The 
case  is  provided  with  carrying  strap  and  a  drawer  for  electrodes.  This 
pattern  may  be  secured  with  24  or  30  cells  with  pole  changer,  with  or 
without  milliamperemeters;  with  18  cells  with  pole  changer,  and  with 
8  and  1 2  cells  without  pole  changer. 


Figure  445.    Eck's  Pole  Changer. 


The  Mclntosh  Twenty-four  Cell  Direct  Current  Battery  is  shown  by  figure 
447.  Similar  batteries  may  be  secured  with  6,  12  or  1 8  cells.  A  bifurcated 
cord  furnishes  the  means  by  which  the  number  of  cells  in  circuit  may  be 
increased  or  decreased  without  shock  to  the  patient. 

The  Chloride  of  Silver  Direct  Current  Battery,  as  pictured  in  figure  448, 
may  be  secured  with  25,  35  or  50  cells,  current  controller  and  pole  changer, 
and  with  or  without  milliamperemeter.  The  cells  of  this  battery  are 
selected  in  series  of  5,  7  or  10,  the  volume  of  current  being  modified  by 
the  current  controller. 

The  Vetter  Dry  Cell  Galvanic  Battery,  as  exhibited  by  figure  449,  is  one  of 
the  most  compact  of  this  class  of  appliances.  The  cell  is  a  modified  form  of 
the  one  shown  by  figure  433.  It  is  claimed  that  with  average  use  these  will 
furnish  a  steady  and  constant  current  for  from  one  to  three  years.  The 


244 


ELECTRO-THERAPEUTICS. 


cells  are  of  high  electro-motive  force  with  but  little  internal  resistance  and 
great  recuperative  power.  The  cells  are  usually  in  series,  the  two  terminals 
being  connected  with  a  Vetter  carbon  current  controller,  which  forms  a  por- 
tion of  each  outfit. 

Switchboards. 

The  use  of  primary  cells  requires  some  form  of  switchboard,  by  means 
of  which  the  wires  from  the  various  cells  may  be  assembled  and  united  in 
one  series.  They  are  so  adjusted  that  two  or  any  other  number  of  the  cells 
forming  the  battery  may  be  circuited  together. 

The  Switchboard  traced  in  figure  450  is  one  of  the  ordinary  forms. 
It  can  be  purchased  for  any  number  of  cells  desired.  It  is  not  necessary 
that  the  switchboard  be  constructed  with  one  button  for  every  cell,  because 


Figure  446.    Twenty-four  Cell  Direct  Current  Battery,  as  Designed  by  Hyslop. 

in  the  higher  numbers  several  cells  may  be  connected  with  a  single  button, 
and  the  buttons  numbered,  as  will  be  seen  in  the  illustration.  "The  levers 
may  be  single  or  double ;  in  the  single  lever  variety,  the  first  cell  must 
always  be  placed  in  the  circuit,  and  in  increasing  this  number,  each  succeed- 
ing cell  is  added  in  rotation,  so  that  in  ordinary  cases  the  first  cells  of  the 
series  are  always  in  use. 

By  means  of  a  double  lever,  if,  for  instance,  ten  cells  be  required  with 
thirty  forming  the  battery,  either  the  first,  second  or  third  series  of  ten  may 
be  employed  independent  of  the  balance;  in  other  words,  any  ten  cells 
that  are  in  rotation  may  be  selected. 

Table  Plates  and  Wall  Cabinets. 

Plain  table  plates  are  frequently  purchased  by  those  who  do  not  desire 
to  incur  the  extra  expense  of  more  elaborate  outfits. 


TA13LF.     PLATES. 


245 


The  Venetian  Table  Plate,  as  illustrated  by  figure  451,  shows  one  of  the 
smaller  of  this  class  of  instruments.  It  is  10  by  12  inches  in  size  and  con- 
tains a  double-lever  switch,  faradic  coil  and  pole  changer. 


Figure  447.    Mclnt 


Twenty-four  Cell  Direct  Current  Battery. 


Large  Table  Plates,  those  of  the  improved  forms,  in  which  a  cell  selector, 
milliamperemeter,  rheostat,  current  selector,  pole  changer,  faradic  coil, 
etc. ,  are  neatly  arranged,  may  be  procured  of  various  designs  and  prices, 
according  to  the  ideas  of  the  manufacturer  and  the  wishes  of  the  pur- 


Figure  448. 


Chloride  of  Sih 
Battery. 


Direct  Current 


Figure  449.    Vetter's  Dry  Cell  Galvanic 
Battery. 


chaser.  The  one  shown  in  figure  452  comprises  a  double-lever,  27-button 
switch,  a  2 5 -button  German- silver  wire  rheostat  furnishing  a  resistance  of 
2,500  ohms,  milliamperemeter,  pole  changer,  switches  for  current  selection 
and  faradic  coil.  The  secondary  portion  of  the  latter  is  wound  with  1,500 
yards  of  No.  36  insulated  wire  tapped  at  500  and  1,000  yards  respectively. 


246 


ELECTRO-THERAPEUTICS. 


The  Wall  Cabinet  shown  by  figure  453  illustrates  one  of  the  many  forms 
designed  for  use  where  economy  of  space  is  an  essential  qualification.  Bat- 
teries of  this  class  are  arranged  in  such  a  manner  that  they  may  be  attached 


Figure  450.    Switchboard  with  Double  Levers. 


Figure  451.    Venetian  Table  Plate. 


to  the  wall,  while  the  cells  may  be  located  in  a  closet,  adjoining  room  or 
basement.  They  may  be  of  any  size  and  include  such  apparatus  as  the 
purchaser  may  select.  The  pattern  illustrated  projects  from  the  wall 
13^  inches,  is  \6\  inches  wide  and  34  inches  in  height.  It  contains  36  but- 


Figure  452.    Large  Table  Plate. 


Figure  453.    Wall  Cabinet. 


tons  with  double-lever  switch;  a  2  5 -button  wire  rheostat,  each  button  afford- 
ing a  resistance  of  100  ohms;  a  milliamperemeter,  pole  changer,  switch  for 
current  selection,  two  faradic  coils,  one  muscular,  the  other  sensory,  and 
an  automatic  rheotome  for  interruption  of  the  direct  current. 


CABINKT    BATTERIES. 


Cabinet  Batteries. 


247 


These  comprise  that  form  of  battery  in  which  the  cells  are  contained  in 
some  kind  of  movable  cupboard,  usually  of  desk-like  construction,  in  the  top 
of  which  the  controlling  apparatus  is  placed.  The  cells  may  be  of  any 
desired  form  and  the  mechanism  arranged  to  suit  the  purchaser.  Nearly 
all  manufacturers  of  standard  appliances  construct  office  batteries  tha't 
more  or  less  resemble  the  illustration,  detailed  descriptions  of  which  may 
be  obtained  from  their  catalogues. 

The  Improved  Cabinet  Battery,  shown  by  figure  454,  exhibits  a  desirable 
form  of  battery  for  office  use.  Besides  supplying  a  direct  current  having  a 


Figure  454.    Improved  Cabinet  Battery. 


maximum  force  of  36  cells,  it  is  provided  with  an  improved  system  of  farad- 
ic  coils,  designed  by  Herdman.  It  also  comprises  a  milliamperemeter, 
pole  changer,  rheostat  with  25  buttons,  each  involving  a  resistance  of 
100  ohms,  double-lever  cell  selector,  current  selecting  switch,  etc.  It  is 
68  inches  high  and  occupies  a  floor  space  21  by  46  inches. 


THE  INDUCED  CURRENT  OR  FARADISM. 

Faradic  currents  are  obtained  by  passing  a  direct  current  through  what 
is  termed  a  "primary  coil."  This  is  interrupted  by  vibrators  that  may  be 
fine  or  slow  and  vary  according  to  the  construction  of  the  coil  and  the 
voltage  of  the  current  employed.  As  exhibited  in  batteries  for  general 


ELECTRO-THERAPEUTICS. 

use,  the  currents  are  of  two  varieties,  primary  and  secondary,  the  latter 
sometimes  called  the  induced  current.  These  currents  when  united  form 
what  is  called  a  combined  current.  Some  manufacturers  combine  faradic 
with  portable  galvanic  batteries,  thus  enabling  the  physician  to  obtain 
either  current  from  the  same  machine.  While  this  seems  practicable,  as 
a  matter  of  fact  both  currents  are  seldom,  if  ever,  employed  on  the  same 
patient  at  any  one  time,  and  as  the  combination  of  the  two  increases  the 
size  of  either,  the  transportation  of  so  much  additional  weight  seems 
unnecessary.  If  the  batteries  be  purchased  separate,  only  that  one  which 
is  required  need  be  carried.  While  one  is  in  use,  the  remaining  battery 
may  be  placed  in  service  elsewhere.  This  is  impossible  when  both  are 
combined  in  one  machine.  Portable  faradic  batteries  are  usually  manu- 
factured from  one  of  two  types,  either  a  bichromate  of  potash  cell  or  some 
form  of  the  so-called  dry  cells  described  by  figures  432  and  433.  A  persul- 
phate of  mercury  cell,  formerly  quite  popular,  is  now  seldom  employed. 


Figure  455.    Falcon  Faradic  Battery. 

The  Falcon  Faradic  Battery,  as  represented  in  figure  455,  is  especially 
designed  for  family  use.  The  current  is  generated  by  a  single  cell,  such  as 
is  described  by  figure  433.  It  possesses  many  advantages  over  the  bichro- 
mate of  potash  pattern  for  this  purpose.  It  maintains  an  even  power  and 
intensity  until  exhausted.  It  requires  no  recharging.  There  is  no  fluid  to 
be  spilled,  and  it  can  be  placed  in  action  by  moving  a  single  switch.  The 
coil  is  so  constructed  that  the  various  currents  may  be  gradually  and  evenly 
regulated.  The  vibrations  are  regular  and  the  current  free  from  uneven 
pulsations,  the  effect  upon  the  patient  being  pleasant  and  soothing.  It 
supplies  the  primary,  secondary  and  combined  currents,  any  one  of  which 
may  be  graduated  from  a  mild  current  to  one  of  high  tension.  The  battery 
is  furnished  with  metallic  foot  plate,  sponge  disc  electrodes,  conducting 
cords  and  handles. 

The  Mclntosh  Faradic  Battery  Elements,  as  shown  by  figure  45 6,  differ  from 
those  employed  to  secure  the  direct  current  in  being  heavier  and  provided 
with  a  cell  of  larger  capacity.  The  latter  is  provided  with  a  drip-cup 


INDUCED    CURRENT     ISATl'ERIES. 


249 


somewhat  on  the  principle  of  the  Mclntosh  direct  current  cells.  The 
induction  coil  is  mounted  on  a  neat  hard  rubber  base,  the  latter  furnishing 
the  cell  cover  or  hydrostat.  To  this  the  coil,  binding  posts  and  rheotomc 
are  secured,  as  are  also  the  zinc  and  carbon  elements,  the  latter  being 
attached  to  the  under  surface. 

The  Mclntosh  Physicians'  Faradic  Battery,  as  shown  by  figure  457,  con- 
sists of  a  single  cell  with  elements  as  illustrated  by  figure  456,  the  whole 
encased  in  a  neat  hardwood  case  6  inches  in  width,  9  inches  in  length  and 
7  inches  in  height. 

Hyslop's  Physicians'  Faradic  Battery,  as  shown  by  figure  458,  consists  of 
a  portable  faradic  battery,  the  principal  features  of  which  are  a  high  ten- 
sion coil,  from  which  a  current  of  great  intensity  may  be  obtained,  and  an 
adjustable  rheotome,  by  which  the  frequency  of  interruptions  may  be 
varied. 

Upon  the  length  of  wire  surrounding  a  primary  coil  (provided  it  is  kept 
within  the  field  of  magnetic  influence)  depends  the  number  of  lines  of  mag- 


i1  ijjure  456.     Cell  of  Mclntosh's  Faradic  Battery. 


netic  force  developed,  while  upon  the  number  of  magnetic  lines  of  force 
depends  the  intensity,  or  power,  of  the  current  to  overcome  resistance.  The 
therapeutic  value  of  a  long,  fine  secondary  wire  is  therefore  apparent. 
The  secondary  portion  of  the  coil  in  this  instrument  contains  4,500 
feet  of  No.  36  insulated  wire,  the  diameter  of  which  is  five  one- 
thousandths  of  an  inch.  This  is  divided  into  three  sections  of  1,500 
feet  each.  One,  two,  or  all  three  of  these  sections  may  be  circuited  at  the 
will  of  the  operator,  by  means  of  a  four-point  switch  mounted  on  the  plate, 
rendering  this  single  coil  practically  equivalent  to  four  coils,  viz.,  primary; 
secondary,  1,500  feet;  secondary,  3,000  feet,  and  secondary,  4,500  feet. 

The  combination  rheotome  may  be  so  adjusted  as  to  vary  the  number 
of  interruptions  from  a  pendulum  movement  of  variable  frequency  to  a 
strained  or  singing  ribbon,  the  frequency  of  the  vibrations  of  which  is 
extremely  high. 

The  case  is  of  mahogany,  7  by  8  by  1 1  inches,  weighs  complete  fourteen 

pounds,  and  contains  underneath  the  plate  four  muriate  of  ammonia  dry 

cells,  similar  to  those  shown  by  figure  433.      These  are  directly  connected 

with  a  five-point  switch,  by  means  of  which  any  number  of  the  cells  may 

.  be  selected  to  operate  the  coil. 


250 


ELECTRO-THERAPEUTICS. 


Persulphate  of  Mercury  Faradic  Batteries,  as  illustrated  in  figure  459,  and 
often  called  the  Gaiffe  pattern,  are  desirable  only  because  they  are  compact. 
Before  the  introduction  of  the  so-called  dry  cells,  they  commanded  a  large 
sale  because  they  were  more  portable  than  other  forms  of  faradic  batteries. 
The  new  type  of  cell  has  to  so  great  an  extent  superseded  batteries  of  the 
Gaiffe  pattern  that  there  is  now  practically  no  demand  for  the  latter.  The 
quality  and  strength  of  current  derived  from  this  form  of  cell  are  all  that 
can  be  desired.  The  objections  to  them  are  the  trouble  necessary  to  recharge 
the  cells  when  exhausted  and  their  construction,  which  is,  as  a  rule,  cheap, 
thus  rendering  them  liable  to  get  out  of  order.  They  are  manufactured 
with  either  one  or  two  cells. 

Herdman's  Faradic  Table  Plate,  as  pictured  in  figure  460,  consists  of  two 
faradic  coils,  one  of  which,  the  sensory  or  high  tension  coil,  is  supplied 
with  a  rheotome  or  current  interrupter  that  consists  of  a  long  ribbon  of 
steel  bound  at  both  termini.  This  steel  ribbon  is  so  arranged  that  it  may 
be  strained  to  a  high  degree  of  tension.  This  extreme  tension  is  productive 


Figure  457.     Mclntosh's  Physicians'  Faradic  Battery. 

of  rapid  rheotomic  interruptions,  causing  the  current  to  spend  itself  super- 
ficially, thus  paralyzing  the  termini  of  the  sensory  nerves.  The  secondary 
portion  of  the  sensory  coil  is  wound  with  1,500  yards  of  No.  36  insu- 
lated wire.  This  is  tapped  at  500  and  at  1,000  yards.  The  muscular  coil 
being  wound  with  heavy  wire  in  connection  with  a  rheotome  giving  various 
degrees  of  slow  interruptions,  is  productive  of  a  current  of  quantity  and  is 
effective  where  muscular  or  uterine  contraction  is  desired.  This  pattern 
thus  practically  furnishes  six  currents :  The  muscular  primary,  muscular 
secondary,  sensory  primary,  and  sensory  secondary  of  500,  1,000  and  1,500 
yards.  The  battery  requires  four  good  primary  cells  for  successful 
operation. 

Bath  Apparatus. 

The  necessary  current  for  electric  baths  is  usually  alternating,  controlled 
by  a  rheostat  or  a  battery  of  primary  cells  passing  through  a  special  large 
induction  coil.  The  direct  current  is  sometimes  employed,  in  which  case 
an  increased  number  of  cells  is  necessary. 


ELECTRIC    BATH    APPARATUS. 


251 


Electric  baths  may  be  administered  with  almost  any  form  of  bath-tub, 
aided  by  a  faradic  current  of  high  tension,  or  a  direct  current  of  high 
voltage,  the  former  being  usually  preferred.  Many  methods  are  employed 
for  applying  the  current,  but  for  general  treatment,  large  copper  plates  arc 
placed  in  each  end,  the  current  being  caused  to  pass  through  the  body 
lengthwise. 


Figure  458.    Hyslop's  Physicians'  Faradic  Battery. 


The  Mclntosh  Combined  Galvanic  and  Faradic  Bath  Apparatus  consists  of 
a  large  faradic  coil  with  vibrator  and  binding  posts  attached  to  a  horizontal 
plate,  while  suitable  switches,  pole  changers  and  cell  selectors  are  located 
on  an  upright  plate  that  forms  the  back  of  the  machine.  The  whole  is  so 
arranged  that  it  may  be  placed  on  a  table  or  shelf,  or  fastened  to  a  side 


Figure  459.    Persulphate  of  Mercury  Faradic  Battery. 

wall.  The  primary  and  secondary  faradic  wires  are  of  large  size  in  order 
to  secure  a  quantity  of  current  sufficient  for  administration.  This  appa- 
ratus, while  it  may  be  used  with  any  form  of  tub,  is  arranged  for  use  with 
those  of  special  construction,  wherein  various  electrodes  are  so  placed  that 
the  current  may  be  applied  to  any  desired  portion  of  the  body.  Any  part 


l£  0  i 


252 


ELECTRO-THERAPEUTICS. 


of  the  current  may  be  directed  through  any  portion  of  the  body  and  its 
direction  or  polarity  changed  at  will.  It  may  also  be  used  as  an  ordinary 
Faradic  or  galvanic  battery. 

The  Electric  Bath  Tub  with  Stationary  Electrodes,  as  illustrated  by  figure 
462,  has  sides  tapering  toward  both  foot  and  bottom,  is  76  inches  long  on 


Figure  460.    Herdman's  Faradic  Table  Plate. 


Figure  461.    Mclntosh's  Galvanic  and  Faradic 
Bath  Apparatus  No.  1. 


top,  54  inches  long  on  bottom,  16  inches  wide  on  top  at  foot,  and  21  inches 
at  head.  Besides  head  and  foot  electrodes,  it  is  supplied  with  five  pairs  of 
side  or  lateral  electrodes,  by  means  of  which  currents  may  be  directed  to 
almost  any  portion  of  the  body. 

Direct  Current  and  Faradic  Electrodes. 

Electrodes  are  necessary  for  applying  or  receiving  the  electrical  current. 
They  may  be  obtained  in  an  almost  endless  variety  of  forms  and  shapes,  the 


i  Tub  with  Stationary  Electrodes. 


majority  of  which  are  manufactured  for  special  use.  They  are  constructed 
of  various  materials,  with  and  without  insulation.  They  require  consider- 
able care  in  their  preservation,  for  under  the  action  of  electrical  currents 
they  readily  corrode  or  otherwise  change,  thus  forming  imperfect  con- 
ductors. 

Gold  and  platinum  form  exceptions  to  this  rule,  but  owing  to  their  great 


-  \r, 


ELECTRODES. 


253 


expense  they  are  little  employed.  To  secure  the  best  results,  all  metallic 
surfaces  should  be  plated  and  kept  bright  by  polishing.  Sponges,  when 
used,  should  be  frequently  washed  and  sterilized.  Owing  to  the  difficulties 
encountered  in  maintaining  sponges  in  an  aseptic  condition,  woolen  flannel 
or  gauze  is  frequently  substituted. 

As  the  same  electrodes  are  frequently  employed  for  use  both  with  the 
direct  and  Faradic  currents,  no  attempt  will  be  made  to  classify  them 
separately. 

The  Universal  Handle,  portrayed  in  figure  463,  consists  of  a  metallic  rod 
surrounded  with  a  hardwood  sheath  in  handle  form  The  distal  end  is  a 
metallic  shaft  terminating  in  a  flat  metallic  disc,  the  outer  margin  of  which 


Figure  463.    Universal  Handle. 


Figure  464.     Sponge  Electrode. 


is  covered  with  sponge  and  the  inner  with  soft  rubber,  the  two  materials 
being  stitched  together  around  their  margins.  Two  of  these  electrodes  are 
usually  supplied  with  either  the  galvanic  or  the  Faradic  battery.  They 
have  a  general  application  in  the  use  of  both  the  constant  and  interrupted 
currents. 

The  Sponge  Electrode,  exhibited  in  figure  464,  is  a  bell- shaped  cup  provided 
with  a  central  shaft,  the  under  surface  of  which  terminates  in  a  flat  circular 
disc  and  the  outer  with  a  thread  by  which  the  whole  may  be  attached  to  a 
universal  handle.  A  nut  upon  the  shaft  regulates  the  distance  between  the 
disc  and  the  outer  border  of  the  cup.  By  removing  the  latter,  forcing  the 
shaft  through  a  sponge,  and  replacing  the  cup,  the  sponge  may  be  included 
between  the  grasp  of  the  two  and  any  desired  amount  of  compression 
secured  by  means  of  the  nut.  The  sponges  may  be  renewed  at  any  time. 

The  Universal  Handle  with  Interrupter,  pictured  in  figure  465,  is  of  hard 
rubber  with  a  central  metallic  shaft,  connection  through  the  handle  being 


Figure  465.    Universal  Handle  with  Interrupter. 

effected  by  a  spring  and  push  button.  It  is  so  adjusted  that  an  electric 
current  will  not  pass  through  the  handle  unless  the  button  be  depressed. 
With  this  appliance  the  constant  current  may  be  interrupted  at  will. 

The  Hand  Sponge  Electrode,  as  shown  by  figure  466,  consists  of  an  oval 
piece  of  soft  rubber  faced  with  thin  flat  sponge  or  spongiopiline.  A  strap 
across  the  back  enables  the  operator  to  secure  it  firmly  to  the  hand.  As  it 
is  soft  and  flexible  it  may  be  made  to  conform  to  almost  any  surface. 

The  Plain  Sponge  Electrode,  exhibited  by  figure  467,  consists  of  a  small 
cup-shaped  cylinder  into  the  open  end  of  which  one  end  of  a  sponge  may 
be  tucked  or  forced.  It  may  be  of  any  size,  and  is  used  for  diagnostic  or 
therapeutic  purposes. 

The  Adjustable  Band  Electrode,  illustrated  by  figure  468,  consists  of  a 
flexible  hard  rubber  band  of  any  desired  size.  A  medium-sized  sponge  is 


254 


ELECTRO-THERAPEUTICS. 


secured  in  the  inner  face  of  the  band  and  so  connected  with  the  battery 
circuit  that  the  current  is  imparted  only  to  the  sponge.  The  band  is 
employed  to  hold  the  electrode  in  the  desired  position. 

Similar  electrodes  without  bands  may  be  held  in  place  by  means  of  the 
clothing.  All  are  advantageous  when  long  application  is  desired.  Flan- 
nel is  advised  as  a  covering  because  it  can  be  removed  and  washed.  Vari- 
ous sizes  can  be  purchased,  those  adapted  for  the  neck,  leg  and  arm  being 
more  commonly  used. 

The  Folding  Foot  Electrode,  displayed  by  figure  469,  consists  of  a  copper 
or  zinc  plate  hinged  in  its  center  for  compact  folding  and  with  a  back  cov- 
ered with  soft  rubber  to  secure  insulation.  It  is  well  adapted  for  applica- 
tion to  one  or  both  feet.  Plates  that  do  not  fold,  for  water  immersion  and 
with  or  without  insulation,  may  also  be  procured. 


Figure  466.    Hand  Sponge  Electrode. 


Figure  467.    Plain  Sponge  Electrode. 


The  Ball  Electrode,  shown  by  figure  470,  consists  of  a  metallic  sphere.  It 
is  used  with  either  the  direct  or  Faradic  current,  usually  for  diagnostic 
purposes.  It  may  be  obtained  in  various  sizes. 

The  Disc  Electrode,  displayed  in  figure  471,  may  be  employed  with  almost 
any  current  and  with  or  without  a  cloth  cover.  It  may  be  purchased  in 
various  sizes. 

Duchenne's  Points,  as  exhibited  by  figure  472,  consist  of  sharp-pointed 
conical .  electrodes,  the  tips  of  which  are  bent  at  an  acute  angle  with  the 
shaft.  They  are  employed  for  local  Faradization  of  single  muscles. 


Figure  468.     Adjustable  Band  Electrode. 


Figure  469.    Folding  Foot  Electrode. 


The  Metallic  Brush,  portrayed  by  figure  473,  consists  of  a  shank  or  handle 
terminating  in  a  broom-shaped  wire  brush.  It  is  used  principally  for  dry 
Faradization  in  cases  where  there  is  profound  cutaneous  anesthesia  or 
analgesia. 

The  Long  Handled  Sponge  Electrode,  illustrated  by  figure  474,  comprises 
a  slender  insulated  stem  terminating  in  a  sponge  or  flannel-covered  disc, 
usually  from  two  to  three  inches  in  diameter.  It  is  employed  princi- 
pally for  use  under  the  clothing  in  cases  where  it  is  not  practical  to  secure 
the  removal  of  the  latter. 


ELECTROLYSIS. 


255 


Sanger-Brown's  Spinal  Electrode,  as  represented  in  figure  475,  consists  of 
a  T-shaped  plate  of  perforated  zinc  attached  to  a  similar,  shaped  piece  of 
spongiopiline,  the  latter  somewhat  larger  than  the  metallic  face.  This 
arrangement  furnishes  means  for  conducting  an  electrical  current  to  any 
portion,  or  all  of  the  spine.  When  desired,  portions  of  the  electrode  may 
be  excluded  by  placing  a  small  piece  of  rubber  cloth  or  gutta  percha  tissue 
beneath  certain  parts.  The  length  of  the  electrode  is  usually  16  inches, 
the  breadth  of  the  main  stem  3  inches,  and  the  breadth  of  the  base  7  inches. 
The  Plain  Foot  Plate,  portrayed  in  figure  476,  consists  of  a  sheet  of  zinc 
usually  square  with  a  female  tip  connector  attached  to  one  corner.  Gen- 
erally they  are  from  8  to  9  inches  square. 


Figure  470.     Ball 
Electrode. 


Figure  471.     Disc 
Electrode. 


Figure  472.    Duchenne's  Electrodes. 


Hayes'  Abdominal  Electrode  consists  of  a  thin  flexible  metallic  disc,  one 
side  of  which  is  covered  with  spongiopiline.  The  metal  portion  is  pro- 
vided with  radiating  slits,  as  shown  in  figure  477,  that  permit  of  bending  the 
electrode  in  any  desired  form.  This  allows  it  to  be  closely  adjusted  to 
uneven  surfaces.  Usually  it  is  8  inches  in  diameter,  and  is  made  of 
tinned  copper  or  pure  tin. 

Goelet's  Clay  Electrode  for  abdominal  use,  as  illustrated  by  figure  478, 
consists  of  a  small  metallic  pan  filled  with  a  pillow-shaped  bag  of  sculp- 
tor's clay.  This  material,  used  first  by  Apostoli  for  this  purpose,  holds 
moisture  for  a  considerable  time.  Generally  it  is  6  by  8  inches  in  size. 

Electrolysis. 

The  term  electrolysis,  as  generally  applied  in  surgery,  is  restricted  to  the 
electro-chemical  dissolution  of  morbid  growths  by  the  application  of  a  suit- 
able current  through  needles  that  have  been  introduced  directly  into  the 


Figure  473.     Metallic  Brush. 

tumor  mass..  The  apparatus  necessary  may  be  either  a  direct  current 
battery  of  from  12  to  24  cells,  or  an  Ed'ison  low  pressure  street  current  of 
no  volts.  The  needles  employed  should  be  gold,  or  at  least  gold-plated, 
that  they  may  resist  the  oxidizing  effects  produced  by  the  chemical  action 
of  the  current  on  the  tissues  and  needle.  The  needles  employed  should  be 
connected  with  the  negative  pole.  Two,  four,  six,  eight  or  more  needles 
may  be  employed,  and  where  subcutaneous  operations  are  attempted,  that 


256 


ELECTRO-THERAPEUTICS. 


the  skin  may  not  be  affected,  such  needles  may  be  insulated  throughout  a 
portion  of  their  length.  According  to  Rockwell,  needles  with  semi-cutting 
edges  are  preferred  because  more  easily  introduced,  and  he  recommends 
those  with  either  bayonet  or  spear  points. 


Figure  474.    Sponge-Covered  Electrode  with  Long  Handle. 


Electrolysis  Needles  may  be  procured  in  the  shapes  shown  by  figure  479, 
straight,  half  curved  or  full  curved,  and  of  any  size.  They  may  be  either 
plain  or  partially  insulated. 

Some  form  of  holder  is  usually  employed,  not  only  for  the  manipulation 
of  the  needle,  but  to  connect  it  with  the  battery.  This  may  be  single  or 
constructed  for  any  given  number  of  needles,  usually  from  one  to  four  being 
employed. 


Figure  475.    Sanger-Brown's  Spinal  Electrode. 


Figure  476.    Plain  Foot  Plate. 


Electrolytic  Needle  Holders,  as  traced  in  figure  480,  consist  of  a  large  tip 
or  shoulder  connecting  with  the  battery  cord,  to  which  are  attached  the 
various  fine  cords  that  connect  with  the  needles.  These  fine  cords  may  be 
of  any  number,  each  terminating  in  a  small  tip  of  a  size  that  readily  fits 
the  needle  to  be  used. 


Figure  477.    Hayes'  Abdominal  Electrode. 


Figure  478.    Goelet's  Abdominal  Clay  Electrode. 


Superfluous  hair  may  be  removed  by  electrolysis.  The  requirements  are 
a  battery  of  8  to  24  cells,  one  of  about  18  zinc-carbon  elements  being 
usually  preferred.  The  needles  may  be  of  the  ordinary  jeweler's  brooch 


DIRECT    CURRENT     DYNAMO. 


257 


pattern,  or  iridio-platinum  needles,  the  latter  being  preferable.     Any  form 
of  holder,  either  plain  or  with  interrupter,   may  be  employed 

The  Electrolytic  Needle  Holders,  shown  by  figures  481  and  482,  prac- 
tically differ  only  in  that  one  is  supplied  with  an  interrupter.  Either  may 
be  successfully  used  in  holding  needles  for  the  removal  of  hair. 


THE  DIRECT  CURRENT  DYNAMO. 

This  current  can  be  employed  for  many  surgical  purposes  by  means  of 
various  forms  of  apparatus.  By  the  aid  of  rheostats,  described  on  page  241, 
it  may  be  decreased  in  quantity  and  used  as  a  direct  (galvanic)  current,  or 


Figure  479.    Straight  and  Curved  Needles  for  Electrolysis. 

to  operate  a  Faradic  coil.  By  converters  and  alternators  the  sinusoidal  cur- 
rent may  be  obtained.  By  converters  and  transformers  the  voltage  may  be 
reduced  and  the  quantity  increased,  rendering  it  suitable  for  galvano-cautery 
and  the  illumination  of  diagnostic  lamps. 

The  Edison  Converter  or  Motor  Alternator,  as  illustrated   in   connection 
with  a  transformer  by  figure  483,  is  designed  for  the  purpose  of  converting 


Figure  480.    Needle  Holders  with  Cord  and  Tip,  for  Use  with  Needles  Shown  by  Figure  479. 

the  direct  dynamo  current  into  an  alternating  current.  The  necessity  for 
this  instrument  has  arisen  from  the  fact  that  the  direct  current  can  not  be 
satisfactorily  transformed  into  the  current  of  great  quantity  and  low  pressure 
necessary  in  galvano-cautery  and  snaring  operations. 

The  converter,  when  connected  with  a  no- volt  direct  current  circuit, 
travels  at  a  high  rate  of  speed  and  generates  or  delivers  an  alternating 
electro-motive  force  of  about  seven-tenths  of  the  pressure  of  the  original 


Figure  481.    Plain  Hard  Rubber  Needle  Holder. 

current.  This  alternating  current  of  77  volts  may  be  controlled  by  a  rheostat 
and  the  sinusoidal  current  obtained,  or  may  be  passed  through  a  trans- 
former for  cautery  purposes. 

The  Edison  Cautery  Transformer,  as  illustrated  in  connection  with  a 
converter  by  figure  483,  is  designed  for  the  purpose  of  transforming  the 
alternating  dynamo  current  of  from  52  to  104  volts  into  a  current  of  quan- 


258 


ELECTRO-THERAPEUTICS. 


tity  and  low  voltage  for  galvano-cautery  instruments  and  the  illumination 
of  diagnostic  lamps.  There  are  many  patterns  of  transformers  manufactured 
for  this  purpose,  but  the  one  above  illustrated  is  considered  the  most 
simple  and  effective,  consisting  as  it  does  of  but  two  coils,  a  primary  and 
a  movable  secondary.  The  alternating  current  being  passed  through  the 
primary  coil,  excites  by  induction  the  movable  secondary,  from  which  the 
current  of  quantity  is  obtained. 

The  volume  of  the  current  passing  through  the  electrode,  or  lamp,  is  reg- 
ulated by  the  adjustment  of  the  secondary  coil,  which  is  furnished  with  a 
rack  and  pinion  device  for  this  purpose. 


Figure  482.    Hard  Rubber  Needle  Holder  with  Interrupter. 

The  Edison  Converter  and  Transformer  Combined,  as  shown  in  figure 
483,  is  designed  to  enable  the  direct  no  to  120  volt  Edison  current  to  be 
used  with  absolute  safety  for  electro- cautery  work,  and  will  be  found  of 
the  greatest  assistance  to  those  physicians  whose  offices  are  equipped  with 
this  current.  It  is  also  suitable  for  hospital  work,  as  nearly  all  the  promi- 
nent institutions  are  lighted  by  the  direct  current.  The  apparatus  is 
mounted  on  a  highly  polished  oak  base,  and  is  provided  with  an  attach- 
ment plug  and  flexible  cord  for  connecting  the  instrument  to  the  mains. 


Figure  48'!.     The  Edison  Converter  and  Trari'sformer  Combined. 

The  Kennelly  Galvanic  and  Faradic  Adapter,  as  illustrated  by  figure 
484,  is  one  of  the  most  complete  and  satisfactory  instruments  by  which  the 
no  or  120  volt  direct  current  may  be  adapted  to  the  various  forms  of  electro- 
therapeutic  treatment.  It  not  only  supplies  a  direct  or  galvanic  current  of 
from  60  to  1 20  volts,  but  also  primary  and  secondary  Faradic  currents,  each 
of  varied  strength.  It  consists  of  a  hard  rubber  cylinder  upon  which  is 
wound  in  suitable  grooves  several  hundred  feet  of  German  silver  wire, 
having  a  high  resistance.  The  patient  is  protected  from  the  effects  of  an 
accidental  increase  in  current  by  a  16  candle-power  lamp  placed  in  the  cir- 


THE    DIRECT    CURRENT    DYNAMO. 


259 


Figure  484.     Kennelly's  Galvanic  and  Faradic  Adapter. 

cuit  of  each  of  the  leading-in  wires,  so  that  in  case  of  a  short-circuit,  by  the 
fusing  of  the  fine  wire  in  the  lamp,  the  current  would  be  immediately  cut 
out.  A  third  lamp  is  employed  in  connection  with  the  rheostat,  and  is  used 
to  secure  a  finely  graduated  current,  which  prevents  shocks  to  the  patieut. 
The  Faradic  coil  is  of  the  DuBois-Reymond  type,  a  secondary  coil  being 
wound  upon  a  separate  spool,  the  whole  containing  1,800  yards  of  No.  34 
wire.  This  is  tapped  in  six  places,  producing  as  many  variations  of 
strength,  each  depending  on  the  number  of  sections  of  the  secondary  coil 
that  is  circuited.  It  is  provided  also  with  a  delicate  milliamperemeter 


Figure  485.     Kennelly's  Therapeutic  Sinusoidal 
Machine. 


Figure  480. 


Vetter  System  for  Controlling  an 
Incandescent  Current. 


260 


ELECTRO-THERAPEUTICS. 


and  suitable  switches,  by  means  of  which  the  current  may  be  fully  con- 
trolled. 

The  direct  dynamo  current  may  also  be  employed  to  secure  what  is  now 
known  as  the  sinusoidal  current.  This  may  be  secured  by  means  of  the 
Kennelly  machine,  shown  by  figure  485. 

The  Kennelly  Therapeutic  Sinusoidal  Machine,  for  use  with  a  no  to 
120  volt  direct  current,  consists  of  a  small  alternator  driven  by  a  delicate 
motor.  The  field  frame  is  of  laminated  iron,  supported  by  castings  and 
has  twelve  poles.  On  each  pole  is  a  spool  with  two  windings  of  wire,  one 
coarse  and  one  fine. 

By  proper  connections,  the  continuous  primary  current  is  changed  into 


TRUAX 
GREENE  S,  CO. 


Figure  487.    Author's  Modification  of  Feddern's  Actual  Cautery  Battery. 


alternating  current  waves  of  the  sinusoidal  type.  The  current  may  be 
varied  by  means  of  the  Bailey  rheostat,  shown  in  figure  441.  The 
sensations  are  more  agreeable  than  those  of  the  Faradic  coil. 

The  Vetter  System  for  Controlling  a  Direct  Incandescent  Current,  as 
sketched  in  figure  486,  consists  of  a  current  adapter,  a  volt  controller,  a 
carbon  current  controller  and  a  milliamperemeter.  The  current  adapter 
is  inserted  into  a  light  socket  and  includes  in  its  circuit  a  16  candle-power 
lamp,  thus  limiting  the  current  capacity  to  one-half  ampere.  A  volt  con- 
troller is  supplied,  by  means  of  which  any  desired  voltage  from  o  to  55 
may  be  selected.  In  addition  to  these  the  system  includes  a  carbon  current 
controller,  by  means  of  which  a  current  in  fine  gradations  may  be  obtained, 
the  amount  of  which  is  registered  by  the  milliamperemeter. 


THE  INDIRECT  CURRENT  DYNAMO. 

This  may  also  be  employed  in  electro-surgery,  but  owing  to  the  contin- 
ual changing  of  polarity  of  the  current,  which  occurs  from  7,200  to  16,000 
times  per  minute,  according  to  the  construction  of  the  machine,  its  field  of 
usefulness  is  limited.  It  may  be  used  as  the  sinusoidal  current  when  con- 


INDIRECT    CURRENT    DYNAMO. 


261 


trolled  by  a  rheostat,  to  operate  a  Faradic  coil  or,  by  the  aid  of  a  transformer, 
for  galvano-cautery  and  illumination. 

The  alternating  incandescent  lighting  current  of  52  or  104  volts,  by  its 
continual  and  frequent  changing  of  polarity,  delivers  the  true  sinusoidal 
wave.  It  is  necessary  only  to  employ  some  reliable  means  of  controlling 
the  volume  of  this  current  to  adapt  it  to  therapeutic  purposes.  This  may 
be  effected  by  a  rheostat  or  current  controller.  One  similar  in  construction 
to  the  Jewell  graphite  rheostat,  illustrated  by  figure  438,  is  most  suitable, 
as  by  this  form  all  possibility  of  a  dangerous  increase  of  current  in  the 
patient's  circuit  is  avoided. 


Figure  488.    Edison's  Primary  Cautery 
Battery. 


Figure  489.    Galvano-Cautery  Storage  Battery. 


GALVANO-CAUTERY. 

Galvano-cautery  is  that  form  of  cauterization  secured  by  the  application 
of  an  electrically  heated  wire.  A  wire  may  be  heated  by  attempting  to 
pass  through  it  a  current  of  great  quantity.  The  resistance  of  the  wire 
to  the  passing  current  arrests  the  latter  and  converts  it  into  heat.  The 
degree  of  heat  is  in  proportion  to  the  resistance  of  the  wire  and  to  the 
quantity  of  current.  Platinum  wire,  owing  to  its  great  resistance,  is  best  for 
this  purpose.  This  method  of  cauterization  is  preferable  to  the  thermo- 
cautery  (see  page  218)  because  the  degree  of  heat  is  not  only  under  perfect 
control,  but  the  minute  wire  of  the  galvano-cautery  can  be  employed  in 
numberless  cases  where  the  bulky  heated  irons  of  the  old-fashioned  cautery 
could  not  be  introduced.  Galvano-cautery  may  be  secured  by  several 
methods,  among  which  are  primary  batteries  of  large  amperage, 


262 


ELECTRO-THERAPEUTICS. 


secondary  or  storage  batteries,  direct  current  dynamo  and  indirect  current 
dynamo. 

Galvano-cautery  in  its  simplest  form  is  produced  by  a  primary  battery, 
and  as  the  current  is  one  of  quantity  and  not  of  voltage,  large  cells  are 
required,  usually  from  one  to  three  comprising  a  battery.  Generally  those 
of  an  electro-motive  force  of  two  volts  each  are  required,  the  amperage  of 
the  battery  varying  from  6  to  20.  It  may  be  employed  for  actual  cautery 
and  heated  wire  operations. 

The  Author's  Modification  of  Feddern's  Cautery  Battery  differs  from  the 
original  pattern  in  the  elimination  of  much  of  the  internal  resistance  of  the 
old  design  and  an  increase  of  external  conduction.  An  improved  elevating 
rod  automatically  regulates  the  immersion  of  the  elements.  The  current 


Figure  490.    Plain  Galvano-Cautery  Holder. 

discharged  is  in  proportion  to  the  immersion  of  the  plates,  hence  the  amount 
may  be  regulated  to  suit  the  electrode  in  use  and  work  required.  It  is 
illustrated  by  figure  487. 

Edison's  Primary  Cautery  Battery,  as  shown  by  figure  488,  comprises 
eight  large  cells  of  the  Edison-Lalande  type.  The  elements  are  zinc  and 
black  oxide  of  copper,  the  exciting  liquid  being  a  solution  of  caustic  potash. 
It  is  claimed  that  this  battery  will  not  polarize  and  that  it  possesses  no  local 
action.  They  may  be  obtained  in  various  sizes,  the  one  shown  being  one  of 
the  best  for  general  use. 

Secondary  or  Storage  Batteries. 

These  are  advised  for  those  who  object  to  the  fluid  battery  for  cautery 
operations  and  who  desire  portability.  Usually,  they  consist  of  an  accum- 
ulator or  receptacle  into  which  an  electric  current,  either  from  a  direct 


Figure  491.    Plain  Galvano-Cautery  Handle  with  Interrupter. 

current  incandescent  system  or  a  series  of  gravity  cells,  may  be  conducted 
and  there  stored.  Generally,  they  are  supplied  with  a  rheostat,  which 
enables  the  operator  to  discharge  the  amount  of  current  necessary  for  the 
electrodes  employed,  be  it  large  or  small,  thus  avoiding  overheating  or 
loss  of  current.  They  may  be  obtained  from  one,  two  or  three  cells,  as 
desired.  An  ordinary  battery  should  discharge  one  ampere  for  thirty-five 
consecutive  hours,  or  ten  amperes  for  three  and  a  half  consecutive  hours, 
etc.  From  this  it  is  easy  to  calculate  the  life  of  the  battery  when 
fully  charged.  If,  for  example,  ten  amperes  be  the  average  current  em- 
ployed and  one  minute  be  the  average  duration  of  an  operation,  210  oper- 
ations should  be  expected  from  the  instrument  without  recharging. 

The  Galvano-Cautery  Storage  Battery,   shown  by  figure  489,   consists  of 
two  cells  having  an  electro-motive  force  of  4  volts    and    a    capacity  of 


CAUTERY   HANDLKS  AND  SNARLS. 


263 


35  ampere  hours.    A  suitable  rheostat  enables  the  operator  to  discharge  any 
desired  amount  of  current.    The  battery  is  7^  by  9  by  13  inches,  and  weighs 
when  filled,  44^  pounds. 

Direct  and  Indirect  Current  Dynamos  may  be  used  for  galvano-cautery 
purposes  by  the  aid  of  transformers,  converters,  etc.,  as  described  by 
figures  483  to  486. 

Cautery  Handles  and  Snares. 

These  may  be  procured  in  various  forms,  from  a  plain  handle  for  the 
attachment  of  knives  to  the  complicated  instruments  used  for  snaring  pur- 
poses 

The  Plain  Galvano-Cautery  Holder,  shown  by  figure  490,  consists  of  two 
plain  shafts  of  heavy  construction  joined,  yet  insulated,  by  means  of  a 


Figure  492.     Schech  s  Universal  Galvano-Cautery  Handle. 

hard  rubber  bridge.  The  tips  are  each  provided  with  a  central  slotted 
opening,  and  with  a  conical-shaped  terminal  face.  A  milled  collar,  travel- 
ing on  a  screw,  surrounds  the  tip,  by  means  of  which  the  central  opening 
may  be  enlarged  or  decreased,  thus  enabling  the  operator  to  adjust  various 
sizes  of  knife  shafts.  It  is  well  adapted  for  the  use  of  those  who  make  their 
own  tips. 

The  Plain  Galvano-Cautery  Handle  with  Interrupter,  shown  by  figure 
491,  exhibits  one  of  the  most  simple  patterns  that  is  supplied  with  an  inter- 
rupter By  means  of  the  latter  the  current  may  be  instantly  turned  off  or 
on.  The  electrodes  may  be  securely  attached  by  means  of  small  set  screws. 


Figure  493.    American  Pattern  Galvano-Cautery  Handle  and  Snare. 

Schech's  Universal  Galvano-Cautery  Handle,  as  illustrated  by  figure  492, 
mav  be  used  either  as  a  cautery  holder  or  snare.  An  interrupter  of  fine 
adjustment  and  with  trigger  movement  enables  the  operator  to  turn  the 
current  either  on  or  off.  The  handle  is  slotted  on  its  upper  margin  and 
provided  with  a  sliding  head,  by  means  of  which  a  snaring  wire  may  be 
actuated.  This  head  is  provided  with  a  finger  loop  and  screw  attachments 
for  securing  the  wire.  The  distal  terminals  of  the  handle  are  curved 
upward  in  bayonet  form  that  they  may  serve  as  guides  for  the  sliding  wire 
The  proximal  end  of  the  handle  is  in  ring  form  to  provide  a  point  for 
thumb  contact  in  closing  the  engaged  loop. 


264 


ELECTRO-THERAPEUTICS. 


The  American  Pattern  of  Galvano-Cautery  Handle,  as  evidenced  in 
figure  493,  may  be  used  for  snaring  purposes.  It  consists  of  a  hard  rubber 
handle  of  large  size  provided  with  a  button  interrupter  and  windlass.  By 
means  of  the  latter,  a  wire  loop  may  be  fully  controlled  and  shortened  as 
desired.  The  loop  attachment  is  in  bayonet  form  and  may  be  removed 
and  cautery  knives  attached. 


Figures    494 


497  498  499 

Cautery  Electrodes. 


Figures       603 


506  507  508 

Cautery  Electrodes. 


Figures       512 


514  515 

Cautery  Electrodes. 


517 


Cautery  Electrodes. 

Although  cautery  electrodes  are,  to  all  appearances,  very  simple  instru- 
ments, yet  much  care  and  precision  should  be  exercised  in  their  construc- 
tion. Strictly  scientific  principles  should  be  employed,  in  order  that  the 
whole  energy  of  the  current  may  be  concentrated  in  the  platinum  tip, 
instead  of  being  wasted  before  reaching  that  point. 


STATIC  ELECTRICITY. 


265 


Static  Electricity. 

Static  electricity,  as  now  employed  in  medicine  and  surgery,  is  gen- 
erated by  what  is  known  as  an  influence  machine.  Among  the  many  pat- 
terns for  producing  this  form  of  electrical  current  are  those  devised  by 
Holtz,  Wimshurst,  Voss,  Glaser  and  others,  the  two  first  mentioned  being 
generally  preferred. 


Figures     518 


519 


520  521 

Cautery  Electrodes. 


524 


Figures     525  520 


527      .          528  529  530  531 

Cautery  Electrodes. 


532 


533 


Figures     534 


537  538          539          540 

Cautery  Electrodes. 


A  static  machine  consists  of  a  series  of  plates,  usually  of  glass  and  in 
pairs,  one  of  each  pair  being  fixed,  and  the  other  caused  to  revolve,  or  both 
may  revolve  if  in  opposite  directions. 


266 


ELECTRO-THERAPEUTICS. 


Flat  metal  discs  or  sectors  are  fastened  to  the  face  of  each  revolving 
plate  in  most  patterns.  These  are  caused  to  come  in  contact  with  stationary 
metal  brushes  when  the  plates  are  revolved.  The  resulting  friction  creates 
or  generates  electricity.  This  is  collected  as  fast  as  formed  by  stationary 
combs  mounted  adjacent  to,  but  not  in  contact  with,  the  plates.  Any  number 
of  pairs  of  plates  may  be  placed  in  a  single  case  and  the  generating  power 
of  the  medium  correspondingly  increased.  Constructed  and  operated 
under  proper  conditions,  a  current  of  static  or  frictional  electricity  results 
when  the  movable  plates  are  revolved.  This  may  be  conducted  and  stored 
in  Leyden  jars,  to  be  discharged  at  will.  When  large  plates  are  employed, 
these  jars  may  often  be  dispensed  with. 

The  best  size  for  plates  is  from  26  to  36  inches  in  diameter,  the  latter 
furnishing  the  most  powerful  current.  Owing  to  the  largely  increased  cost 
of  36-inch  machines,  those  of  26  to  30  inches  are  generally  employed.  Four 


Figure  544.    Morton-Wimshurst-Holtz  Influence  Machine. 

pairs  or  eight  plates  form  the  smallest  number  available  for  general  use. 
Three  pairs  are  employed  by  some  operators,  but  as  a  rule  they  do  not 
prove  as  satisfactory  as  the  eight  and  ten  plate  patterns.  For  general  use 
eight  plates,  each  28  to  30  inches  in  diameter,  are  to  be  preferred. 

As  now  manufactured,  the  better  machines,  particularly  those  of 
the  Holtz  pattern,  are  not  only  available  for  therapeutic  use,  but  they  form 
the  most  efficient  means  for  exciting  a  Crooke's  vacuum  or  other  tube  for 
securing  the  Roentgen  X-ray  results.  For  this  purpose  alone  this  machine 
has  no  superiors,  either  in  form  or  method.  This  latter  feature  makes  its 
possession  almost  a  necessity,  for  it  thus  answers  a  two-fold  purpose 

Makers  have  now  overcome  the  objections  that  for  generations  prevented 
the  general  adoption  of  this  current,  so  that  to-day  it  is  rapidly  growing 
in  favor.  Good  machines  are  not  only  reliable  but  inexpensive  to  operate, 
while  the  financial  returns  from  an  increased  office  practice  as  a  rule  quickly 
repay  the  seemingly  large  initial  investment. 

The  Wimshurst  static  machine  consists  of  circular  plates  in  pairs,  all 


STATIC    ELECTRICITY  267 

revolving,  the  two  forming  each  pair  revolving  in  opposite  directions. 
This  pattern,  which  was  once  quite  popular,  has  been  gradually  replaced  by 
the  Holtz  machine. 

The  Morton-Wimshurst-Holtz  Influence  Machine  is  constructed  with  a 
fixed  plate  in  connection  with  each  revolving  one.  As  shown  by  figure  544, 
they  are  so  arranged  that  two  stationary  plates  are  between  each  pair  of 


Figure  545.    Induction  or  Ruhmkorff  Coil. 

revolving  plates.  The  metallic  brush  and  sectors  are  dispensed  with.  A 
machine  of  this  class  is  capable  of  generating  powerful  currents,  a  spark  of 
10  to  15  inches  in  length  being  produced  by  a  machine  containing  four 
pairs  of  plates  30  inches  in  diameter.  This  great  force  of  current  is  created 
by  induction  caused  by  the  rotating  of  the  circular  plates  in  close  proximity 
to,  and  on  both  sides  of  the  stationary  plate.  An  initial  charge  of  current 


Figure  546.     Fluoroscope. 

from  a  self-generating  machine,  such  as  the  Wimshurst,  is  necessary  to  excite 
the  plates  of  the  Holtz  machine,  which,  after  taking  up  this  initial  charge, 
will  retain  it  for  an  indefinite  time  or  according  to  the  humidity  of  the  at- 
mosphere. A  small  Wimshurst  machine  is  contained  in  the  same  case  but  is 
separate  from  the  Holtz  machine.  By  the  aid  of  this  small  machine  the 
induction  machine  may  be  quickly  recharged  at  any  time. 

A  most  convenient  method  of  operating  every  form  of  static  machine  is  by 


268 


ELECTRO-THERAPEUTICS. 


means  of  a  small  electric  motor,  one  developing  one-quarter  horse  power 
being  of  sufficient  strength  to  operate  the  largest  size  of  static  machine. 

Motors  for  this  purpose  may  be  obtained  suitable  for  any  direct  incan- 
descent lighting  system,  or  where  commercial  electricity  is  not  obtainable,  a 
water  motor  may  be  used  with  satisfactory  results. 

The  electrodes  necessary  are  usually  about  ten  in  number  and  are 
supplied  by  manufacturers  with  each  machine,  those  with  points  and  ball 
terminals  being  the  most  useful. 


THE  ROENTGEN  X-RAY. 

The  most  important  functions  of  the  X-ray  in  surgery  are  the  detection 
of  dislocations  and  fractures,  the  location  of  foreign  bodies,  and  the  diagnosis 
of  growths  composed  wholly  or  in  part  of  bone.  These  results  may  be 
obtained  either  by  visual  examination  through  a  fluoroscope,  or  by  means 
of  an  X-ray  photograph. 

One  of  the  greatest  difficulties  which  presents  itself  to  the  physician  is 
the  selection  of  the  most  suitable  apparatus  for  the  production  and  utiliza- 
tion of  X-rays.  This  is  not  only  complicated  by  makers  of  a  single  class  of 


Figure  547.    The  Tesla  Coil  and  Transformer. 

instruments  who  manufacture  apparatus  of  varying  degrees  of  quality,  but 
because  there  are  also  different  methods  for  securing  identical  results. 

Generally  speaking,  there  are  three  plans  of  operating :  The  influence  or 
static  machine,  the  induction  or  Ruhmkorff  coil,  and  the  Tesla  coil  and  trans- 
former. Either  of  these  when  properly  constructed  and  energized  and  accur- 
ately manipulated,  will  produce  an  electrical  discharge  over  an  air  gap  that 
is  limited  only  by  the  size  of  the  generator  and  the  energy  or  power 
behind  it. 

Recent  investigations  seem  to  indicate  that  the  most  satisfactory  results 
are  obtained  from  a  12  to  15  inch  spark,  particularly  where  examinations  of 
the  chest,  shoulders  or  abdomen  are  desired.  For  the  hands,  feet  or  lower 
arm,  a  6  to  8  inch  spark  has  proven  successful  in  the  hands  of  most  oper- 
ators. 

The  influence  or  static  machine  illustrated  in  figure  544,  represents  an 


ROENTGEN    X-RAY.  269 

eight-plate  apparatus,  which,  under  favorable  conditions,  generates  an 
electro-motive  force  capable  of  penetrating  an  air  gap  varying  from  10  to 
14  inches.  With  this  machine  not  only  may  X-ray  work  be  successfully 
performed,  but  it  also  possesses  the  greater  advantage  of  being  useful  for 
therapeutic  treatment.  The  latter  feature  alone,  when  properly  brought 
to  the  notice  of  the  average  surgeon,  is  sufficient  to  convince  him  of  the 
desirability  of  selecting  this  form  of  apparatus  in  preference  to  one  that 
can  be  used  only  for  diagnostic  work. 

The  Induction  or  Ruhinkorff  Coil,  displayed  in  figure  545,  is  of  the  Will- 
young  pattern.  It  consists  of  five  principal  parts :  A  large  core  or  central 
portion  of  soft  iron ;  a  primary  coil  or  a  number  of  turns  of  heavy  insulated 
wire  surrounding  the  iron  core;  a  secondary  coil  comprising  several  thou- 
sand feet  of  very  fine  insulated  wire  surrounding  the  primary  coil ;  a  con- 
denser for  storing  any  excessive  current,  and  a  current  breaker  or  inter- 
rupter. The  source  of  energy  employed  in  operating  this  coil  may  be  that 
derived  from  a  direct  current  dynamo  or  from  a  battery  of  storage  cells. 
It  is  manufactured  in  various  sizes,  with  spark  capacity  varying  from 
3  to  15  inches,  according  to  the  size  of  the  coil. 

The  Tesla  Coil  and  Transformer,  represented  in  figure  547,  is  one  of 
many  forms  in  which  this  apparatus  may  be  obtained.  It  consists  of  an 
induction  coil  supplied  with  a  number  of  widely  separated  turns  of  primary 
wire  and  comparatively  few  loops  of  highly  insulated  secondary  wire,  the 


Figure  548.    Crooke's  Tube. 

ratio  between  the  two  turns  being  usually  about  24  to  i ;  a  condenser  and 
a  transformer.  The  source  of  energy  used  in  operating  this  form  of  appa- 
ratus may  be  that  obtained  from  an  alternating  electric  light  circuit,  which, 
being  oscillating  in  its  action,  obviates  the  use  of  a  current  interrupter. 

Crooke's  Tube,  as  shown  in  figure  548,  is  only  one  of  the  many  forms  for 
the  production  of  X-rays,  each  being  especially  adapted  to  some  particular 
form  of  apparatus.  Among  the  most  prominent  for  effective  use  are  the 
Monell  tube,  employed  in  connection  with  the  static  current ;  the  Jacobi  tube, 
for  use  with  the  induction  or  Ruhmkorff  coil,  and  the  Thompson  double-focus 
tube,  for  use  with  the  Tesla  coil.  Each  of  its  kind  and  with  the  vacuum 
properly  adjusted  to  suit  the  length  of  spark  employed,  when  properly 
manipulated,  will  give  satisfactory  results. 

The  Fluoroscope,  exhibited  in  figure  546,  maybe  obtained  in  two  forms  of 
screen,  upon  either  of  which  the  shadow  cast  by  the  X-ray  may  be 
observed,  one  the  tungstate  of  calcium,  the  other  the  barium-platinum 
cyanide.  The  former  is  the  most  economical,  but  the  latter  far  excels  in 
clearness  and  distinctness  of  outline.  Unfortunately,  however,  it  rapidly 
deteriorates  when  in  use. 

Fluoroscopes  may  be  obtained  from  dealers  in  various  sizes,  among  the 
most  common  of  which  are  screens  4  by  6,  5  by  7,  6  by  8,  7  by  9,  and  8  by  10 
inches.  They  may,  however,  be  secured  in  sizes  and  shapes  to  suit  the 
requirements  of  the  operator. 


CHAPTER  XVII. 


MINOR. OPERATIVE  SURGERY. 

Under  this  heading  we  will  illustrate  and  describe  such  instruments  and 
appliances  as  are  usually  employed  in  minor  operations  on  the  soft  tissues, 
omitting  those  that  are  intended  for  use  in  regional,  bone  and  special 
operations. 

As  stated  in  the  introduction  of  this  work,  we  have  endeavored  to  select 
a  list  of  furniture,  instruments,  appliances,  dressings,  medicines,  etc., 
suitable  for  such  operations,  either  in  or  out  of  the  hospital.  In  attempting 
to  supply  this  schedule,  we  realize  that  the  ideas  and  methods  of  each  indi- 
vidual surgeon  vary,  to  a  greater  or  lesser  extent,  from  those  of  other 
operators,  and  that  in  this  list,  and  those  that  will  follow,  articles  will  be 
found  included  that  by  many  are  not  deemed  necessary,  and  others  omitted 
that  will,  by  some,  be  considered  essential.  It  is  hoped,  however,  that  it 
will  serve  as  a  general  guide  in  the  selection  and  checking  off  of  the  instru- 
ments and  various  other  articles  required  in  an  operation. 

GENERAL  OPERATIONS  IN  HOSPITAL. 

Furniture. 

Operating  Table,  see  figures  178  to  190 

Table  Cover,  see  page  1 1 1 

Perineal  Pad,  see  figure  198 

Leg  Holder,  see  figures  194  to  197 

Operating  Stool,  see  figure  192 

Dressing  Table,  see  figure  204 

Instrument  Table,  see  figure  205 

Suture  Stand,  see  figure  206 

2  Wash-Stands  and  Bowls,  see  figures  215  to  220 

Irrigating  Apparatus,  see  figures  227  to  238 

Illuminating  Apparatus,  see  figures  1446  to  1469 

Slop  Jar,  see  figures  240  and  241 

5  Trays,  assorted,  see  figures  242  to  245 

2  Dressing  Basins,  see  figure  260 

Soiled  Dressing  Receptacle,  see  figure  239 

Instrument  Sterilizer,  see  pages  163  to  170 

Dressing  Sterilizer,  see  pages  152  to  169 

Garment  Sterilizer,  see  pages  152  to  169 

Sterilized  Water,  hot  and  cold,  in  tanks,  see  figures  314  and  315 

General  Appliances. 

Ether  and  Ether  Inhaler,  see  figures  329  to  335 

Chloroform  and  Chloroform  Inhaler,  see  figures  336  to  338 

Tongue  Forceps,  see  figures  343  to  345 

Mouth  Gag,  see  figures  346  to  349 

Electric  Battery,  see  figures  446  to  460 

Stomach  Pump  or  Tube,  see  figures  1641  and  1662 

270 


GENERAL    OPERATIONS    IN    HOSPITAL.  271 

General  Appliances. —  (Continued.) 

Aspirator,  see  figures  371  to  375 

2  Hypodermic  Syringes,  see  figures  360  to  370 

i  Extra  Large  Hypodermic  Syringe,  see  figures  366  to  368 

Fever  Thermometer,  see  figure  79 

4  Nail  Cleaners,  see  figures  283  to  285 

Surgical  Soap  in  Sterilized  Container,  see  figures  273  to  275 

4  Hand  Brushes,  see  figure  277 

Razor,  see  figures  281  and  282 

Bed  Pan,  see  figures  166  to  170 

Male  Urinal 

Female  Urinal 

Male  Catheters,  metal  and  flexible,  see  figures  1255  to  1267 

Female  Catheters,  see  figure  1053 

Hot  Water  Bottles  or  Cans,  see  figures  401  to  404 

Wound  Syringe,  see  figure  697 

Plaster  of  Paris  Bandage  Cutter,   see  figures  2230  to  2239 

Thermo-Cautery,  see  figure  399  or  400 

Shears  or  Heavy  Scissors 

Transfusion  Tube  and  Tablets  of  Sodium  Chloride,  see  figure  392 

Garments,  Dressings,  Sutures,  Etc. 

Surgeon's  Gown,  see  figure  262 

Assistants'  Gowns,  see  figure  263 

Nurses'  Gowns,  see  figure  263 

Patients'  Robes,  see  figure  267 

Spectators'  Coats,  see  figure  266 

Surgeons'  Rubber  Aprons,  see  figure  264 

Sheets 

Blankets 

Towels 

Sponges  or  Substitutes,  see  figures  686  to  689 

Sponge  Holders,  see  figures  690  to  692 

Rubber  Adhesive  Plaster,  see  figure  789 

Isinglass  Adhesive  Plaster  on  Muslin,  see  figure  790 

Absorbent  and  lodoform  Gauze,  see  page  353 

Absorbent  Cotton,  see  page  355 

Plain  Cotton,  see  page  358 

White  Woolen  Flannel 

Roller  Bandages,  assorted,  see  page  360 

Safety  Pins,  see  figure  803 

Rubber  Dam,  see  page  360 

Gutta  Percha  Tissue,  see  page  360 

Rubber  Drainage  Tubes,  see  figure  699 

Glass  Drainage  Tubes,  see  figure  707 

Splint  Material,  see  figures  2223  to  2226 

Sutures,  Silk,  see  page  322 

Sutures,  Catgut,  see  page  318 

Sutures,  Silver  Wire,  see  figure  737 

Sutures,  Silkworm  Gut,  see  figure  734 

Sutures,  Kangaroo  Tendon,  see  figure  715 

Sutures,  Horsehair,  see  figure  735 

Rubber  Gloves,  sterilized,  see  figure  268 


272  MINOR    OPERATIVE    SURGERY. 

Medicines,  Etc. 

Tablets,  Bichloride  of  Mercury 

Carbolic  Acid,  5  per  cent. 

lodoform 

Collodion 

Alcohol 

Solution  of  Cocaine 

Whisky  or  Brandy 

Teaspoon 

Tablespoon 

Tumbler 

Feeding  Tube 

Sick  Feeder 

Aromatic  Spirits  of  Ammonia 

Olive  Oil,  Sterilized 

Morphine  Tablets 

Tablets  Permanganate  of  Potassium 

Oxalic  Acid 

Strychnia  Tablets 

Hemostatic  Tablets 

Strong  Vinegar  for  cleansing  skin  from  blood  and  oily  matters 

Camphorated  Oil 

Surgical  Instruments. 

Knives,  see  figures  549  to  597 

Tissue  Forceps,  see  figures  604  to  607 

Dressing  Forceps,  see  figure  608 

Retractors,  see  figures  614  to  624 

Director,  see  figures  625  to  630 

Scissors,  see  figures  631  to  635 

Rubber  Bandage,  see  figure  637 

Esmarch's  Strap  and  Chain,  see  figure  637 

Probes,  see  figure  636 

Hemostatic  Forceps,  see  figures  647  to  676 

Tenaculum,  see  figure  581 

Aneurysm  Ligature  Carrier,  see  figure  580 

Needles,  see  figures  739  to  749 

Needle  Holder,  see  figures  753  to  768 

GENERAL  OPERATIONS  OUT  OF  HOSPITAL. 
Furniture,  Etc. 

(To  be  provided  at  residence.) 
Plain  Table,  about  2  by  4  feet 

Table  Cover,  consisting  of  two  folded  Blankets,  Sheets  and  Rubber  Sheet 
4  Chairs,  wood  or  cane  seat 
2  Small  Square  or  Oblong  Tables 
Suture  Stand 

Wash- Stand,  with  two  Bowls  and  Pitchers 
Two  Buckets 
Alcohol 
Whisky  or  Brandy 


GENERAL    OPERATIONS    OUT    OF    HOSPITAL.  273 

Furniture,  Etc. — (Continued.) 
Teaspoon 
Tablespoon 
Tumbler 

6  Clean  (not  new)  Towels 
Bed  Pan 
New  Washboiler 

General  Appliances,  Etc. 
(To  be  provided  by  surgeon.) 

Ether  and  Ether  Inhaler,  see  figures  329  to  335 

Chloroform  and  Chloroform  Inhaler,  see  figures  336  to  338 

Mouth  Gag,  see  figures  346  to  349 

Tongue  Forceps,  see  figures  343  to  345 

Hypodermic  Syringe,  see  figures  360  to  370 

Fever  Thermometer,  see  figure  79 

4  Hand  Brushes,  sterilized  and  wrapped  in  gauze,  see  figure  277 

Surgical  Soap  in  Sterilized  Container,  see  figures  273  to  275 

Nail  Cleaner,  see  figures  283  to  285 

Razor,  see  figures  281  and  282 

Catheter  (Male  or  Female)  see  figures  1255  to  1267 

Shears  or  Heavy  Scissors 

Perineal  Pad,  see  figure  198 

Irrigator  (Fountain  Syringe)   see  figure  693 

2  Trays,  see  figures  242  to  245 

Instrument  Sterilizer,  see  pages  163  to  170 

Dressing  Sterilizer,  see  pages  152  to  169 

Krug's  or  similar  Frame,  see  figure  180 

Portable  Leg  Holder,  see  figure  197 

Head  Mirror  or  Reflector,  see  figure  1460 

Garments,  Dressings,  Sutures,  Etc. 

Surgeons'  Gowns,  see  figure  262 

Nurses'  Gowns,  see  figure  263 

Assistants'  Gowns,  see  figure  263 

Patient's  Robe,  see  figure  267 

Towels 

Sponges  or  Substitutes,  see  figures  686  to  689 

Sponge  Holders,  see  figures  690  to  692 

Rubber  Adhesive  Plaster,  see  figure  789 

Isinglass  Adhesive  Plaster,  see  figure  790 

Absorbent  Gauze  and  lodoform  Gauze,  see  page  353 

Absorbent  Cotton,  see  page  355 

Roller  Bandages,  see  page  360 

White  Woolen  Flannel 

Safety  Pins,  see  figure  803 

Gutta  Percha  Tissue,  see  page  360 

Rubber  Drainage  Tubes,  see  figure  699 

Sutures,  Silk,  see  page  322 

Sutures,  Catgut,  see  page  318 

Sutures,  Silver  Wire,  see  figure  737 

Sutures,  Silkworm  Gut,  see  figure  734 

Rubber  Gloves,  sterilized,  see  figure  268 

IB 


274  MINOR    OPERATIVE    SURGERY. 

Medicines,  Etc. 

Tablets,  Bichloride  of  Mercury 

Carbolic  Acid,  5  per  cent. 

Boracic  Acid 

lodoform 

Tablets,  Sodium  Chloride 

Tablets,  Permanganate  of  Potassium 

Oxalic  Acid 

Collodion 

Solution  of  Cocaine 

Morphine  Tablets 

Strychnia  Tablets 

Atropia  Tablets 

Camphorated  Oil 

Surgical  Instruments. 

Knives,  see  figures  549  to  597 

Tissue  Forceps,  see  figures  604  to  607 

Dressing  Forceps,  see  figure  608 

Retractors,  see  figures  614  to  624 

Director,  see  figures  625  to  630 

Scissors,  see  figures  631  to  635 

Rubber  Bandage,  see  figure  637 

Esmarch's  Strap  and  Chain,  see  figure  637 

Probes,  see  figure  636 

Hemostatic  Forceps,  see  figures  647  to  676 

Tenaculum,  see  figure  581 

Aneurysm  Ligature  Carrier,  see  figure  580 

Needles,  see  figures  739  to  749 

Needle  Holder,  see  figures  753  to  768 

The  edges  of  knives  may  be  protected  from  injury  by  placing  them  in 
some  form  of  rack  or  case  similar  to  that  shown  by  figure  4.  In  the 
absence  of  anything  better,  they  may  be  wrapped  in  sterilized  gauze.  The 
balance  of  the  instruments,  with  the  exception  of  the  rubber  bandage,  strap 
and  chain,  may  be  safely  carried  in  a  washable  roll-up  pouch  similar  to 
those  shown  by  figure  i. 

The  furniture,  sterilizers,  garments  and  anesthetizing  appliances  nec- 
essary in  cases  of  minor  operative  surgery  having  been  previously  de- 
scribed, we  will  in  this  chapter,  illustrate  only  such  instruments,  dress- 
ings, etc.,  as  are  referred  to  in  the  foregoing  list.  These  will  include 

Knives 

Tissue  forceps 

Dressing  forceps 

Retractors 

Sponges  or  substitutes 

Irrigating  apparatus 

Drains 

Sutures 

Directors 

Scissors 

Probes 

Hemostatic  instruments 


OPERATING    KNIVES. 


275 


Needles 

Needle  Holders 
Dressings,  etc. 


Knives. 


Under  this  head  we  will  include  scalpels,  bistouries  and  such  forms  of 
blunt  and  needle-like  instruments  as  are  usually  purchased  with  the  scalpel 
pattern  of  handle. 


Figure  549.     Scalpel  shown  Full  Size. 

That  the  surgeon  may  obtain  an  accurate  knowledge  of  the  sizes  and 
shapes  or  both  handles  and  blades,  we  illustrate  one  of  the  common  patterns 
of  scalpels,  tracing  it  full  size,  and  in  connection  an  assortment  of  blades 
also  shown  by  full-sized  figures. 

The  Scalpel,  shown  full  size  in  figure  549,  is  manufactured  from  a  single 
piece  of  steel.  That  the  instrument  may  not  be  heavy  and  clumsy  the 
handle  is  as  thin  as  is  consistent  with  a  good  grip.  A  series  of  grooves  or 
corrugations  extend  transversely  across  the  sides  of  the  forward  third  of 


Figures 


552  553  554  555 

Scalpels  of  Regular  Patterns. 


558 


559 


the  handle.  These  indentations  are  sufficient  to  afford  a  good  hold,  even 
when  the  fingers  are  moist  and  slippery.  The  proximal  portion  of  the 
handle  is  thin  and  terminates  in  a  rounded  fish-tail  shape,  so  that  it  may 
be  used  as  a  blunt  dissector  in  separating  or  tearing  apart  fibrous  bands. 

The  surgeon  should  provide  himself  with  a  liberal  number  of  cutting 
instruments,  particularly  of  scalpels,  for  he  should  not  only  be  able  to 
select  one  suitable  for  the  work  in  hand,  but  at  once  to  replace  a  knife 
whose  edge  has  become  dulled  by  use,  roughened  by  contact  with  bone, 


276 


MINOR    OPERATIVE    SURGERY. 


infected  by  being  dropped  upon  the  floor,  or  otherwise  brought  into  septic 
contact. 

The  most  common  form  of  operating  knife  is  the  scalpel,  which  ordi- 
narily consists  of  a  somewhat  stout,  short  blade.  Scalpels  are  employed  in  the 
great  majority  of  surgical  operations.  With  them  many  surgeons  attempt 
major  operations,  such  as  amputations  and  resections,  relying  on  the 
sizes  shown  by  figures  550  to  553  to  the  exclusion  of  longer  or  heavier 
patterns.  The  surgeon  who  has  educated  himself  to  perform  even  oper- 
ations necessitating  deep  incisions,  like  exsections  and  amputations  with  an 
ordinary  scalpel,  will  find  that  he  is  not  only  able  to  prosecute  his  work 
with  a  less  number  of  instruments  and  frequently  to  operate  without  waiting 


Figures      560  561 

Double          • v ' 

Edge  Straight  Sharp 

Scalpel.  Point  Bistouries. 


Center  Point  Scalpels. 


to  obtain  special  patterns  of  blades,  but  that  on  all  occasions  he  is  enabled  to 
employ  the  knife  with  a  higher  degree  of  manual  dexterity.  In  making  a 
proper  incision,  even  of  considerable  length  and  depth,  only  a  limited  extent 
of  the  cutting  surface  of  a  large  knife  is  usually  employed.  That  portion  of 
a  cutting  edge  not  brought  into  contact  with  unsevered  tissues  is  superfluous 
in  that  operation  and  only  adds  to  the  weight  and  length  of  the  instru- 
ment. The  smaller  and  lighter  the  knife,  the  finer  and  more  delicate  is 
that  greatest  of  all  safeguards,  the  surgeon's  sense  of  touch,  and  we  believe 
operators  generally  will  profit  by  becoming  accustomed  to  the  use  of  knives 
as  small  as  is  consistent  with  the  nature  of  the  work  involved. 

Scalpels  vary  in  pattern,  the  more  common  being  known  as  the  "convex" 
and  the  "center  point."  The  first  of  these  is  the  one  usually  employed. 
It  is  illustrated  by  figures  550  to  559.  The  line  of  its  cutting  edge,  commenc- 
ing at  the  shank,  follows  nearly  the  same  curve  as  the  runner  of  a  sled.  For 
the  first  half  of  this  length,  it  is  o'nly  slightly  curved.  Commencing  at  this 


OPERATING     KNIVES. 


277 


point,  the  arc  of  the  curve  lessens  with  its  length,  until  it  meets  the  line 
forming  the  back  of  the  blade,  where  it  terminates  in  a  sharp  point. 

The  pattern  shown  as  the  center  point  scalpel,  figures  564  to  569,  is  con- 
structed so  that  the  point  of  the  blade  is  on  a  line  with  the  center  of  the 
handle  of  the  instrument.  The  curves  of  the  front  and  back  are  nearly 
identical. 

Bistouries  differ  from  scalpels  in  being  longer  and  more  slender.  They 
are  manufactured  in  various  patterns,  with  full  or  partial  cutting  edges, 
terminating  in  sharp,  blunt  or  rounded,  and  probe  or  ball-shaped  extremi- 
ties. Special  varieties  of  bistouries  are  known  as  tenotomes,  Hernia 
knives,  gum  lancets,  etc. 

Tenotomes  are  small,  narrow-bladed  scalpels  or  bistouries  with  long 
necks  or  shanks.  They  are  employed  for  the  subcutaneous  incision  of 


Figs. 


Hernia  Knives. 


Probe-Point  Curved 
Bistouries. 


Str'ght  Probe- 
Point 
Bistouries. 


tendons,  muscles,  fascia,  nerves,  etc.  As  found  in  the  market,  the  blades 
are  usually  from  1 7  to  20  millimeters  long,  by  about  4  millimeters  wide.  As 
a  rule,  they  are  much  too  large,  those  about  two-thirds  of  these  sizes  being 
preferable.  .  . 

Two  varieties  are  advised;  sharp-pointed  for  making  the  primary  incis- 
ion and  blunt-pointed  for  severing  the  tendon  or  other  tissue.  In  most 
cases  the  former  will  be  found  sufficient.  A  blunt  tenotome  may,  however, 
be  substituted  after  the  opening  cut  is  made  if  there  be  danger  of  wounding 
blood-vessels  or  other  tissues.  Curved  instruments  with  the  cutting  edge 
on  the  convex  or  concave  border  may  at  times  be  used  to  advantage,  as,  for 
instance,  in  division  of  the  scapho-astragaloid  ligament. 

It  would  be  well  if  the  cutting-edge  side  of  the  handle  were  grooved  < 
otherwise  marked,  that  its  direction  after  introduction  might  be  at  all  times 
determined. 


278 


MINOR    OPERATIVE    SURGERY. 


They  should  be  of  the  finest  quality,  for  frequently  they  are  required 
for  severing  firm  tissues.  Some  authors,  Sayre,  for  instance,  employ  blunt- 
pointed  instruments  only,  and  say  that  sharp  ones  are  dangerous  to  use. 

The  non-cutting  instruments  before  referred  to  and  illustrated  in 
connection  with  the  knives,  are  tenacula,  aneurysm  ligature  carriers,  double 
hook  or  retractor,  and  the  metacarpal  saw. 

Tenacula  are  instruments  with  slender  shanks,  the  latter  terminating  in 
a  sharp  hook-like  point.  They  are  employed  to  engage  and  draw  forward 
parts  desired  for  observation  or  operation,  to  lift  up  and  separate  distinct 
layers  of  tissue,  and  to  draw  away  from  the  main  mass  and  hold  small  parts 
for  excision,  to  tuck  in  between  sutures  any  pouting  edges  of  approxima- 
ting wound  margins,  etc. 

Artery  or  Aneurysm  Ligature  Carriers  are  blunt-pointed  slender  instru- 
ments of  varying  shapes,  each  constructed  with  a  fixed  handle.  The 


Figures 


Tenotomes. 


terminal  portion  is  provided  with  a  large-sized  eye  near  the  point  and  is  so 
curved  that  a  ligature  may  be  pushed  or  passed  around  an  isolated  vessel  or 
other  structure  requiring  ligation. 

Hernia  Knives,  Tenotomes,  Staphylorrhaphy  Knives,  Gum  Lancets,  etc., 
may  often  be  improvised  from  straight  or  curved  bistouries  by  protect- 
ing portions  of  the  cutting  edge  with  a  narrow  strip  of  sterilized  gauze  or 
coarse  thread  tightly  wrapped  around  the  portion  or  portions  of  the  blade 
not  required  in  the  operation,  as  shown  by  figure  598. 

Parkhill's  Scalpels,  as  outlined  in  figures  599  and  600,  have  blades  of  the 
regular  pattern,  but  with  proximal  ends  formed  into  blunt  instruments  for 
purposes  of  periosteal  elevation  or  tissue  separation.  In  the  first,  the  handle 
tip  is  straight,  while  in  the  second  it  is  curved  on  the  edge.  The  margins, 
though  smooth  and  well  rounded,  are  thin  enough  to  permit  the  use  of  the 
instrument  for  purposes  of  separating  distinct  layers  of  tissue,  for  which 
the  instruments  are  well  adapted. 

Sharpening  and  Testing  Instruments. 

When  cutting  instruments  become  dulled  by  iise,  it  is  not  always 
necessary  to  send  them  away  for  repairs.  Almost  any  surgeon  or  assistant 


OPERATING    KNIVES. 


279 


may  soon  become  adept  in  the  art  of  sharpening  edged  tools,  and  even  small 
nicks  in  a  knife  may  frequently  be  removed  in  a  short  time,  and  either  the 
annoyance  of  operating  with  a  dull  instrument  or  the  expense  incurred  in 
sending  to  an  instrument  maker,  avoided. 


Figures      591 


Regular  Pattern  Scalpels. 


Center  Point  Scalpels. 


The  first  thing  necessary  to  success  is  the  selection  of  a  stone — one  free 
from  hard  grains  and  soft  places,  and  without  flaws.  Washita  and  Arkansas 
stones  are  among  the  best,  the  former,  as  it  cuts  away  the  metal  faster 

Figure  598.     Showing  a  Straight  Bistoury  Wrapped  with  Gauze  for  Use  as  a  Tenotome. 

than  the  Arkansas,  being  the  better  for  sharpening  a  dull  instrument,  while 
for  the  finishing  edge  the  latter  is  unquestionably  the  better  of  the  two. 
After  securing  a  suitable  stone  and  lubricating  its  surface  with  glycerine 


Figure  599.    Parkhill's  Scalpel  with  Straight  Dissector. 

(this  being  the  best  known  lubricant  for  this  purpose),  the  knife  should  be 
lightly  grasped,  as  shown  in  figure  60 1,  so  that  with  a  single  sweep  the  entire 
edge  of  the  knife,  whether  long  or  short,  may  be  brought  in  contact  with 
the  stone  by  the  time  the  knife  reaches  the  end  of  the  stone  in  the  left 


280 


MINOR    OPERATIVE    SURGERY. 


hand.  It  will  be  seen  that  with  a  long  knife  the  point  must  describe  the 
arc  of  a  much  smaller  circle,  and  that  the  movement  really  consists  in  draw- 
ing the  edge  toward  the  operator  instead  of  shoving  it  straight  across  the 
stone.  Great  care  must  be  exercised  with  each  sweep  of  the  knife  to  maintain 
the  same  relative  angle  between  the  axis  of  the  blade  and  the  surface  of  the 


Figure  600.    Parkhill's  Scalpel  with  Curved  Dissector. 

stone.  This,  as  shown  by  figure  60 1,  should  be  about  30°,  and  as  each  sweep 
made  with  the  blade  at  an  angle  greater  or  less  than  this  only  tends  to 
increase  rather  than  decrease  the  labor,  its  importance  must  not  be  over- 
looked. Of  course  themovement  described  in  figure  601  only  whets  the  left 
side  of  the  knife  when  viewed  from  the  edge,  and  the  other  side  must  be 


Figure  601.    Showing  How  to  Hold  a  Scalpel  for  Sharpening. 

sharpened  by  a  return  movement  exactly  like  the  first.  The  finishing 
touches  should  be  given,  as  shown  in  figure  602,  with  the  knife  drawn  back- 
ward, observing  the  same  directions  as  before. 

Avoid  grasping  the  handle  tightly,  because  the  edge  must  rest  lightly 
and  easily  on  the  stone. 


Figure  6C2.    Showing  How  to  Hold  a  Knife  When  Finishing  the  Sharpening  Process. 

Various  methods  are  employed  for  testing  the  qualities  of  metal  and 
keenness  of  edge  in  cutting  instruments.  Nicks  or  defects  in  the  edge  of  a 
knife  or  similar  instrument  may  be  detected  by  drawing  the  cutting  s.ur- 
face  slowly  across  the  border  or  outer  margin  of  the  finger  nail,  the  blade 
being  held  nearly  at  a  right  angle.  If  the  movement  be  slowly  and  deli- 


TISSUE    FORCEPS.  281 

cately  made,  the  instrument  will  show  a  tendency  to  stop  whenever  a  nick 
or  imperfect  edge  is  brought  into  contact  with  the  nail. 

The  quality  of  a  cutting  edge,  as  to  its  hardness,  softness  or  the  exist- 
ence of  a  wire  edge,  may  be  determined  by  placing  the  flat  of  the  blade  in 
the  same  relative  position  to  the  plane  surface  of  the  finger  nail  as  would 
be  exhibited  by  a  knife  while  being  sharpened  on  a  hone.  By  drawing  the 
knife  across  the  nail  in  this  position,  if  the  edge  shows  a  tendency  to  turn 
over  or  "wire  up,"  it  is  doubtless  too  soft,  and  should  again  be  applied  to 
the  hone  when  better  results  may  be  obtained.  If  this  application  across 
the  nail  produces  a  fine  serrated  effect  on  the  knife  by  cracking  or  breaking 
off  minute  particles  from  the  edge,  it  may  be  assumed  that  the  blade  is  too 
brittle,  a  defect  that  can  hardly  be  remedied  by  sharpening. 


Figure  603.    Test  Drum  for  Trying  Edges  and  Points  of  Instruments. 

The  Test  Drum,  set  forth  in  figure  603,  was  devised  for  testing  the  points 
of  sharp  instruments.  It  is  particularly  applicable  to  eye  and  ear  instru- 
ments, where  a  sharp,  freely  penetrating  point  is  desired.  It  consists  of 
two  small  cylinders  of  metal,  wood,  bone  or  similar  material,  one  of  which 
is  sufficiently  large  to  slip  over  the  outside  of  the  other. 

When  arranged  for  use,  a  thin  piece  of  kid,  split  sheep-skin  or  gold 
beater's-skin,  is  drawn  tightly  over  the  end  of  the  small  cylinder  where  it  is 
firmly  held  in  place  by  crowding  the  outer  one  over  and  around  both  the 
leather  and  the  small  cylinder.  When  properly  adjusted,  this  will  draw  the 
leather  tightly  in  the  same  manner  as  the  raw  skin  is  drawn  upon  a  drum 
head. 

In  testing  an  instrument,  it  is  necessary  only  to  press  the  point  slightly 
against  the  drawn  surface  of  the  skin ;  if  it  perforates  smoothly,  easily  and 
without  noise,  the  point  may  be  accepted  as  good;  if  it  slips  along  the  skin 
without  perforating;  if  it  cuts  roughly  or  imperfectly,  or  if  it  produces  a 
slight  popping  sound  when  penetrating  the  leather,  it  is  imperfect  and 
should  be  resharpened. 

Tissue  Forceps. 

These  serve  to  hold  minute  particles  during  excision,  and  to  lift  up  and 
steady  layers  of  soft  tissue.  They  are  usually  required  in  delicate  dissec- 
tions where  accurate  division  of  distinct  layers  is  necessary.  They  are 
frequently  employed  in  pairs,  particularly  in  opening  the  peritoneal  cavity, 
one  being  used  to  grasp  the  peritoneum  upon  each  side  of  the  exposed 
surface  that  it  may  be  carefully  lifted  away  from  any  underlying  structures 
while  being  opened  with  the  knife  or  scissors.  They  are  generally  of  the 
plain  spring  forceps  type,  embracing  such  patterns  as  are  self -opening  and 
are  closed  by  thumb  and  finger  pressure  on  the  blades.  They  should  be 
provided  with  accurately  adjusted  teeth,  and  the  spring  should  be  delicate, 
otherwise  the  fingers  of  the  operator  will  tire  while  using  them.  They  vary 


282 


MINOR    OPERATIVE    SURGERY. 


in  length  from  4  to  9  inches,  the  latter  being  used  in  intra-abdominal  and 
gynecological  work. 

The  Mouse-Tooth  Tissue  Forceps,  outlined  in  figure  604,  illustrate  the 
simplest  pattern  in  common  use.  The  teeth  are  three  in  number,  two  on 
one  blade  and  one  upon  the  other,  all  so  accurately  adjusted  that  they  will 
match  or  interlace  perfectly.  When  properly  constructed,  the  teeth  should 
incline  slightly  outward,  as  shown  in  the  illustration,  as  they  are  thus 


Figure  604. 


ue  Forceps  with  Three  Teeth. 


each 
The 


better  adapted  for  securing  a  hold  upon  a  flat  surface.     The  blades 
present  a  hollow  or  concave  external  surface,  affording  a  firm  grasp, 
usual  lengths  are  4^  and  5  inches. 

The  Tissue  Forceps  with  fine  teeth,  as  shown  in  figure  605,  differ  from 
those  before  described  only  in  the  number  of  teeth.  This  pattern  with 
seven,  or  one  with  five  teeth,  is  better  adapted  for  delicate  dissections  and 


Figure  605.    Tissue  Forceps  with  Fine  Teeth. 

where  it  is  necessary  to  include  only  a  small  amount  of  tissue  in  the  grasp 
of  the  instrument. 

Senn's  Slide-Catch  Tissue  Forceps,  as  sketched  in  figure  606,  were  designed 
expressly  for  use  in  pocket  cases,  where  compactness  is  a  desideratum.  As 
they  are  constructed  with  a  slide,  they  may  be  used  for  hemostatic  purposes 


Figure  606.    Senn's  Slide  Catch  Tissue  Forcep  with  3  or  5  Teeth. 

in  emergencies.  Two  patterns  are  in  use,  differing  only  in  the  number  of 
teeth,  one  being  supplied  with  three,  the  other  with  five.  The  usual  length 
is  3j4  inches. 

E.  J.  Senn's  Tissue  Forceps,  as  portrayed  in  figure  607,  are  constructed 
with  five  teeth  slightly  inclined  outward  as  in  the  patterns  before  described. 


Figure  607. 


nn's  Automatic  Tissue  Forceps. 


They  are  provided  with  an  automatic  or  self-acting  catch,  by  which,  tissue  in- 
cluded within  the  grasp  of  the  instrument,  may  be  firmly  held  for  an  in- 
definite period  even  if  the  grip  upon  the  forceps  be  temporarily  released. 
This  advantage  will  be  appreciated,  because  in  certain  cases  it  is  necessary 
to  utilize  the  hand  engaged  in  holding  the  tissue  forceps  for  other  purposes. 
This  may  be  accomplished  with  this  instrument  without  detaching  the 


DRESSING    FORCEPS. 


283 


forceps.  To  release  the  grasp  of  the  instrument  it  is  necessary  only  to 
tightly  press  the  blades,  when  by  an  automatic  movement  the  catch  is 
released.  It  is  claimed  that  in  long  and  tedious  dissections  the  use  of  this 
instrument  is  less  fatiguing  than  the  plain  or  ordinary  tissue  forceps.  The 
regular  length  is  4^  to  5  inches. 

Dressing   Forceps. 

These  consist  of  a  slender  form  of  pincette,  terminating  in  a  series  of 
transversely  serrated  teeth.  They  are  described  by  various  authors  as 
plain  artery  forceps,  thumb  forceps,  dissecting  forceps,  and  tissue  forceps. 

As  forceps  without  catches  are  no  longer  employed  for  hemostatic  pur- 


Figure  608.    Plain  Dressing  Forceps. 

poses;  as  almost  any  form  of  self-opening  pincette  might  with  propriety 
be  termed  a  thumb  forceps;  as  "dissecting  forceps"  usually  refer  to 
work  upon  the  cadaver,  and  as  tissue  forceps  are  of  little  use  unless 
provided  with  mouse-teeth,  we  believe  the  term  "dressing  forceps"  to  be 
more  proper  than  any  of  the  others  mentioned. 

Next  to  the  scalpel,  these  are  perhaps  the  most  useful  instruments  em- 
ployed in  surgery.    As  they  are  constructed  with  serrated  teeth,  they  may  be 


Figure  609.    Plain  Dressing  Forceps  with  Fine  Points. 

used  for  removing  sutures,  plasters,  dressings,  splinters  of  bone,  as  cotton 
holders  in  swabbing  out  wounds,  for  removing  foreign  bodies  from  the  soft 
tissues  or  cavities  of  the  body,  etc.  One  or  more  should  be  included  in 
every  operation  set,  whether  large  or  small.  They  are  of  two  patterns — 
spring  handle  and  scissors  handle. 

The  Plain  Dressing  Forceps,  illustrated  in  figure  608,  is  the  pattern  most 
commonly  in  use.  The  jaws  are  somewhat  broad,  while  the  outer  surfaces  of 
both  blades  are  concave  to  afford  a  firm  grasp.  They  are  usually  4,  4^,  5 
and  5^  inches  in  length. 


Figure  610.    Adams'  Splinter  Forceps. 


Figure  611.    Little's  Dressing  or  Splinter  Forceps. 


The  Plain  Dressing  Forceps,  delineated  in  figure  609,  differ  from  the  pre- 
ceding one  only  that  in  this  pattern  the  jaws  are  narrower,  and  so 
better  adapted  for  the  removal  of  foreign  bodies  from  cavities  and  tissues. 
As  the  demand  for  this  model  is  not  great,  they  are  usually  made  in  but  one 
length.  4^  inches. 

Little's  Dressing  Forceps,  as  shown  by  figure  6n,  differ  from  the 
regular  patterns  in  possessing  narrow  and  fine,  yet  strong,  jaws.  They  are 
serrated  not  only  that  they  may  answer  as  dressing  forceps,  but  for  the 
extraction  of  splinters  and  foreign  bodies  generally  from  the  flesh.  They 
are  usually  about  4  inches  in  length. 

Adams'  Splinter  Forceps  differ  from  the  fine  point  forceps,  described  by 
figure  6 10,  only  in  being  of  miniature  size,  usually  about  2^  inches  in 


284 


MINOR     OPERATIVE    SURGERY. 


length.     They  are  particularly  adapted  for  the  removal   of  splinters  from 
the  flesh. 


Figure  612.    Ring  Handle  Dressing  Forceps. 

The  Ring  Handle  Dressing  Forceps,  as  traced  in  figure  612,  are  of  the 
scissors  handle  type  with  long,  slender,  serrated  jaws.  They  are  4^  inches 
in  length. 


Figure  613.    Dressing  and  Polypus  Forceps. 

The  Dressing  and  Polypus  Forceps,  portrayed  in  figure  613,  are  among 
the  oldest  of  their  class.  They  can  be  used  as  dressing  forceps  for  re- 
moving small  polypi,  packing  wounds  and  cavities,  and  many  other  pur- 
poses. The  jaws  are  transversely  serrated,  and  of  a  size  and  shape  that 
render  them  adaptable  to  work  of  a  universal  character.  Their  regular 
length  is  4^  inches. 

Retractors. 

These  are  instruments  provided  with  hook  shaped  extremities,  used  for 
enlarging  a  wound  opening  by  spreading  apart  the  lips  or  walls.  By  con- 
verting a  linear  into  an  oval  opening,  they  serve  to  extend  the  operating 
space  and  increase  the  area  of  the  field  of  observation.  They  should  possess 
a  curved  extremity  sufficient  to  include  the  entire  mass  to  be  retracted ;  a 
smooth,  firm  handle  affording  a  safe  grip,  and  a  shank  strong  enough  to  ad- 


mit of  the  exercise  of  sufficient  retracting  force  without  danger  of  the  instru- 
ment either  bending  or  breaking.  Generally  they  are  employed  in  pairs, 
one  upon  either  side  of  the  wound  opening. 

Parker's  Retractor,  as  defined  in  figure  614,  is  one  of  the  older  patterns 
for  which  there  is  still  a  good  demand.  The  small  and  large  curved  handles 
of  the  retractor  render  it  applicable  in  a  variety  of  cases.  It  matters  not 
which  end  is  employed  as  a  retractor,  the  remaining  one  forms  a  well -shaped 


RETRACTORS. 


285 


handle.  They  are  manufactured  in  pairs,  one  nesting  within  the  other, 
thus  economizing  space  in  transportation.  The  width  is  y%  inch  and  length 
about  6  inches. 

Volkmann's  Retractors,  as  set  forth  in  figures  615  to  619,  in  their  various 
sizes  furnish  valuable  assistance  to  the  operator.  With  their  sharp,  strong 
teeth,  tissues,  either  superficial  or  deep  seated,  may  be  engaged  and  se- 
curely held.  While  the  surgeon  should  provide  himself  with  some  of  the 
larger  retractors,  such  as  those  of  Lange,  as  shown  in  figure  930,  he  should 
include  in  his  armamentarium  two  or  more  of  these  itseful  instruments. 
Their  length  is  about  8  inches. 


Figure  615.    Volkmann's  Single  Hook  Retractor. 


Figure  616.     Volkmann's  2-prong  Retractor. 


Fjgure  617.     Volkmann's  3-prong  Retractor. 


Figure  618.     Volkmann's  4-prong  Retractor. 


Figure  619.    Volkmann's  6-prong  Retractor. 


Halsted's  Retractors  have  a  loop-shaped  handle  and  strong  shank  with 
a  sharp  blade  curved  on  the  flat,  and  presenting  on  its  inner  surface  a  con- 
vex, and  on  its  outer  surface  a  concave  cylindrical  face.  The  concave  face 
enables  the  operator  to  work  to  advantage  with  smaller  skin  incisions  than 
would  otherwise  be  required,  and  its  inventor  claims  that  a  solid  blade  is 


Figure  630.    Halsted's  Retractors,  Superficial  and  Deep. 

ordinarily  to  be  preferred  to  a  forked  one.  The  lower  margin  of  the  blade 
terminates  in  angular  teeth,  each  about  the  size  of  those  found  in  an  ordi- 
nary buck  saw.  While  manufactured  in  five  sizes,  the  general  form  of 
these  instruments  is  portrayed  by  figure  620.  They  are  constructed  with 


286 


MINOR    OPERATIVE    SURGERY. 


three,  four,  six.  eight  and  twelve  teeth  each,  and  with  widths  of  ^,  i,  i^, 
i^  and  2^  inches,  respectively. 

Oilier 's  Retractor,  as  outlined  in  figure  621,  is  constructed  with  a  blunt 
or  slotted  blade  bent  at  a  right  angle,  the  tips  being  slightly  recurved.  The 
length  of  the  blade  is  1 3/8  and  the  length  of  the  retractor  is  8  inches. 

Ferguson's  Retractor,  as  illustrated  in  figure  622,  is  not  only  double  but 
is  usually  supplied  in  pairs,  the  two  being  alike  in  form  but  so  arranged  that 


Figure  621.    Ollier's  Retractor. 


one  nests  within  the  other.  One  end  supplies  a  blunt  retractor  of  such 
curve  as  to  render  it  applicable  in  most  cases  where  the  thickness  of  the 
wall  tissue  is  not  great.  The  opposite  ends  are  in  the  form  of  triple 
hooks,  after  the  pattern  of  Volkmann  previously  described.  The  center  of 
the  handle  or  shank  is  serrated  with  transverse  corrugations  that  furnish  a 


Figure  622.    Ferguson's  Retractor. 

good  grip.  Each  instrument  is  provided  with  a  shield  by  which  the  sharp 
prongs  of  the  hooked  end  are  protected  while  the  blunt  extremity  is  being 
used  as  a  retractor.  The  instruments  are  about  6l/2  inches  in  length  by 
about  -j^-  inch  in  width. 

Senn's  Retractors,   as  pictured    in    figure    623,    like   the   pattern  last 


Figure  623.    Senn's  Retractor. 


The 


described,  are  manufactured  in  pairs,  one  nesting  within  the  other, 
essential  feature  of  this  instrument  is  its  small  size. 

They  are  especially  designed  for  use  in  pocket  cases  where  space  is 
limited.  The  blunt  end  of  these  retractors  is  in  the  form  of  a  wire  loop 
curved  upon  the  flat.  The  toothed  portion  is  after  the  pattern  of  Volk- 
mann with  triple  hooks.  The  length  is  usually  about  4  inches,  the  breadth 


Figure  624.    Owens'  Retractor  Forceps. 

of  the  loop  being  about  ^4  inch,  and  the  distance  across  the  curve  y%  inch. 

Owens'  Retractor  Forceps,  as  designated  in  figure  624,  not  only  possess 
all  the  advantages  of  an  efficient  instrument  for  hemostatic  purposes,  but 


DIRECTORS. 


287 


the  blades  may  be  separated,  each  forming  a  retractor  for  minor  operations. 
They  will  be  found  particularly  useful  in  tracheotomy,  in  mastoid  oper- 
ations, and  in  many  cases  where  the  wound  is  superficial.  When  used 
as  hemostatic  forceps,  the  united  blades  present  efficient  jaws,  par- 
ticularly where  there  is  oozing  from  extended  surfaces  or  where  several 
small  bleeding  vessels  may  be  included  in  a  single  mass  of  tissue.  The  - 
instrument  when  joined  may  also  be  used  as  a  dilator  for  spreading  the  lips 
of  a  wound  either  longitudinally  or  laterally, 

Directors. 

These  consist  of  grooved  or  gutter-shaped  instruments  employed  in  surg- 
ery for  guiding  or  directing  the  course  of  a  cutting  instrument.  They  are 
also  used  to  separate,  raise  and  hold  tissues  that  are  to  be  divided  where 
care  and  accuracy  are  essential,  in  gauging  the  extent  of  an  incision  in  opening 
sinuses  and  fistulas,  in  exposing  arteries,  etc.  They  are  usually  provided 
with  blunt  extremities,  although,  in  some  cases,  in  order  to  penetrate  dense 
tissues,  sharp  or  spear  points  are  necessary.  Whatever  may  be  the  form  or 
construction  of  the  point,  one  or  more  grooves,  to  serve  as  a  guide  for  the 
knife  or  scissors,  is  a  necessary  feature.  When  the  former  is  employed,  the 
back  of  the  cutting  blade  is  turned  toward  the  instrument. 


Figure  625.    Ordinary  Director  with  Tongue  Tie. 


Figure  636.    Sharp-Point  Director  with  Tongue  Tie. 


Figure  627.    Probe-Point  Director  with  Tongue  Tie. 


The  Directors,  sketched  in  figures  625,  626  and  627,  represent  three  vari- 
eties of  points,  all  in  combination  with  a  tongue  tie.  The  first  is  a  plain 
blunt  point,  the  one  most  commonly  in  use.  The  second  will  answer  for 
penetrating  massive  or  compact  tissues,  while  the  third  may  be  used  as  a 
guide  or  probe  to  pass  between  layers  of  tissues  to  follow  the  track  of  sin- 
uses, etc. 


Figure  628.    Kocher's  Director. 


Kocher's  Director,  as  shown  by  figure  628,  is  considered  one  of  the  most 
useful  of  general  instruments.     It  not  only  answers  all  the  requirements  of  a 


288 


MINOR    OPERATIVE    SURGERY. 


director,  but  it  can  also  be  used  as  a  dissector  and  elevator.  In  addition 
to  the  groove  in  the  central  line,  common  to  the  previously  described  forms 
of  directors,  this  pattern  is  provided  with  two  additional  parallel  grooves, 
one  on  either  side,  so  that  should  the  knife  point  slip  it  may  still  be  caught 
and  directed  by  one  of  the  lateral  grooves.  Its  length  is  about  6  inches. 

Ferguson's  Double  Director,  as  imaged  in  figure  629,  consists  of  a  trans- 
versely serrated  handle  terminating  at  each  end  in  a  slightly  curved  di- 
rector. The  directors  are  in  form  something  like  the  longitudinal  half  of  a 
cone,  excepting  that  the  director  face  is  concave,  its  center  presenting  a 
sharply  denned  groove.  The  instruments  are  constructed  with  well-rounded 


Figure  629.    Ferguson's  Double  Director. 

margins  and  somewhat  blunt  terminals,  that  they  may  be  used  as  dissectors 
or  elevators.  The  two  ends  differ  from  each  other  only  in  size,  the  larger 
being  ^  inch  and  the  smaller  %  inch  wide  at  the  base,  the  former 
having  a  grooved  length  of  2^  and  the  smaller  of  i^  inches.  The  smaller 
end  is  perforated  that  it  may  be  used  as  a  ligature  carrier. 


Figure  630.    Ferguson's  Director  and  Aneurysm  Ligature  Carrier. 

Ferguson's  Director  and  Aneurysm  Ligature  Carrier,  as  set  forth  in  figure 
630,  is  similar  to  the  one  last  described,  excepting  that  instead  of  a  small 
director  it  combines  a  ligature  carrier.  The  latter  is  strongly  made  and 
has  a  well-rounded  terminal  end,  so  designed  that  it  may  also  be  used  for 
dissecting  purposes. 

Scissors. 

In  operative  surgery,  these  are  often  used  as  a  substitute  for  the  knife. 
Less  hemorrhage  follows  their  use  than  that  of  the  scalpel,  owing  to  the 
crushing  nature  of  the  cutting  force.  They  are  manufactured  straight, 
angular,  and  curved  on  the  flat,  and  with  sharp,  blunt,  rounded  and  probe 
points.  In  properly  made  scissors,  the  upper,  outer,  riding  or  moving  blade 
is  the  one  operated  by  the  thumb,  hence  scissors  are  almost  invariably  made 


Figure  631.    Ordinary  Surgical  Scissors  with 
One  Sharp  Point. 

• 

right-handed,  or  for  a  right-handed  person.    Left-handed  scissors  (for  a  left- 
handed  person)  are  usually  manufactured  to  order  only. 

The  Plain  Surgical  Scissors,  expressed  in  figure  631,  the  most  common 
and  useful  pattern,  have  one  round  and  one  sharp  point.  With  the  sharp  point 
underneath,  they  can  be  used  for  perforating  tissues,  clothing,  dressings, etc. ; 
with  the  rounded  point  underneath,  there  is  no  danger  of  accidental  harmful 
incisions.  They  are  manufactured  in  lengths  of  4,  4^,  5,  5^  and  6  inches. 


SCISSORS. 


289 


Grey's  Open  Ring  Scissors,  as  shown  in  figure  632,  possess  no  advantage 
excepting  they  admit  of  great  compactness  in  the  combining  of  instruments 
in  small  operating  cases.  They  are  usually  kept  by  dealers  in  only  one 
length,  4^/2  inches. 


Figure  633.    Grey's  Open  Ring  Scissors. 


The  Blunt  Point  Scissors,  represented  in  figure  633,  are  preferred  for 
work  in  the  hospital  and  operating-room  for  cutting  bandages,  dressings, 
sutures,  etc.  They  may  be  procured  in  the  same  lengths  as  figure  631. 


Figure  033.    Blunt  Scissors. 


The  Angular  or  Knee  Bent  Scissors,  as  displayed  in  figure  634,  are  used 
by  many  surgeons  instead  of  the  knife  for  enlarging  an  incision  and  for  divid- 
ing fascia  where  accuracy  is  desired.  Their  angular  form  permits  their  use 
at  depths  in  a  wound  where  straight  scissors  could  not  be  operated.  Their 

usual  lengths  are  4,  4^,  5,  5^  and  6  inches. 


Figure  034.    Angular  or  Knee 
Bent  Scissors. 


Scissors  Curved  on  the  Flat  are  those  in  which  the  blade  or  cutting  por- 
tion is  curved  in  the  direction  of  an  obtuse  angle  with  the  flat  surface  of 
the  handle;  in  other  words,  curved  flatwise  instead  of  edgewise. 

Curved  on  the  Flat  Scissors,  as  indicated  in   figure  635,   are  employed 


Figure  635.    Scissors  Curved  on  the  Flat. 


for  snipping  or  cutting  away  tissues,  such  as  friable  and  uneven  surfaces, 
that  can  not  easily  be  removed  with  a  knife.     They  can  be  operated  quicker 


290  MINOR  OPERATIVE  SURGERY. 

than  a  knife  and  tissue  forceps  and,  in   denuding   a  surface,   the  result  is 
usually  more  thorough.     Their  lengths  are  4j4,  5,  5^  and  6  inches. 

Probes. 

Probes  are  slender,  flexible  rods,  usually  employed  for  exploring  sup- 
purative  tracts  and  recognizing  foreign  bodies.  They  may  be  utilized  for 
tracing  the  direction  and  depth  of  a  sinus  or  fistula,  for  disclosing  the  area 
of  an  abscess,  for  detecting  the  presence  and  extent  of  a  necrosis,  or  locating 
any  narrow  canal,  tube  or  cavity.  They  may  be  of  any  degree  of  hardness, 
varying  from  a  soft,  pure  silver  wire  to  a  firm,  rigid  rod.  As  regularly 
manufactured,  they  can  be  obtained  with  three  varieties  of  points:  Round  or 
"probe- pointed;"  trocar  or  "sharp-pointed, "  and  fenestrated  or  "with  eye." 
The  probe  "with  eye"  will  be  found  useful  in  carrying  ligatures,  etc.,  and 
may  be  made  to  answer  as  an  aneurysm  needle.  While  they  may  be  manu- 
factured from  various  substances,  silver,  either  pure  or  sterling,  is  usually 
employed ;  the  sterling,  because  of  its  hardness,  is  better  adapted  for  gen- 
eral use. 


Figure  636.    Minor  Operating  Probes. 

Minor  Operating  Probes,  as  pictured  in  figure  636,  are  usually  purchased 
in  pairs  and  in  the  combination  above  shown.  The  lengths  most  in  use  are 
4^,  6,  8  and  10  inches. 

Prevention  and  Treatment  of  Hemorrhage. 

As  the  same  appliances  are  frequently  used  for  the  prevention  and  treat- 
ment of  both  arterial  and  venous  hemorrhage,  all  will  be  described  under 
this  head.  This  will  include  instruments  for  controlling  the  local  circula- 
tion, as  well  as  devices  for  partial,  complete,  temporary,  or  permanent 
hemostasis.  The  various  appliances  may  be  classified  as  those  for  elastic 
compression  of  limb,  elastic  constriction  of  limb,  arterial  compression,  forci- 
pressure,  torsion,  ligation,  acupressure,  antiseptic  tampon,  cauterization, 
application  and  extraction  of  heat. 

Elastic  Compression  of  Limb. 

This  consists  in  emptying  the  blood-vessels  of  their  contents  by  tightly 
winding  an  elastic  bandage  spirally  around  the  limb,  commencing  at  the 


Figure  637.    Esmarch's  Elastic  Bandage  with  Strap  and  Chain. 

extremity.  This  procedure,  first  suggested  by  Esmarch,  furnishes  a  con- 
venient and  satisfactory  method  for  preventing  loss  of  blood  during  an 
operation.  If  the  bandage  and  constrictor  are  correctly  applied,  after  the 
removal  of  the  former,  the  limb  will  be  found  to  be  in  a  state  of  perfect 


ELASTIC    CONSTRICTION    OF    LIMB.  291 

ischemia.  It  is  claimed  that  this  method  may  properly  be  employed  in 
the  majority  of  operations  on  the  extremities.  The  exceptions  noted  are 
cases  in  which  the  limb  is  the  seat  of  a  carcinoma,  sarcoma,  or  is  infiltrated 
with  purulent  products,  in  which  cases  detached  cells  of  the  two  former 
or  septic  material  from  the  latter,  might  be  forced  upward  through  the 
meshes  of  the  cellular  tissues,  thus  entering  the  circulatory  channels. 

Esmarch's  Elastic  Bandage,  as  it  appears  in  figure  637,  as  originally 
designed  by  its  author,  consisted  of  an  elastic  web  bandage  2^  to  3  inches 
in  width  and  from  3  to  4  yards  in  length.  As  it  is  extremely  difficult  to 
sterilize  elastic  webbing  without  injuring  its  quality,  this  material  has  been 
supplanted  by  pure  rubber  bandage  of  extra  thickness.  The  bandage  now 
usually  employed  is  3  inches  in  width,  io*4  feet  in  length  and  about  No.  22, 
Brown  &  Sharp's  gauge. 

Esmarch's  Bandage  is  applied  by  winding  the  bandage  around  the  limb 
in  a  spiral  manner  as  shown  in  figure  638,  commencing  at  the  distal  end 
of  the  limb  and  extending  to  a  point  some  distance  above  the  seat  of 
operation.  The  bandage  at  this  point  may  be  supplemented  by  a  rubber 
cord  provided  with  a  suitable  hook  and  chain,  as  shown  by  "B, "  or  better 
still,  by  a  heavy  flat  rubber  band  as  exhibited  in  figure  637,  and  commonly 
known  as  Esmarch's  tourniquet.  After  securing  the  cord  or  band,  the 
elastic  bandage  may  be  removed  by  unwinding  it  from  above  downward. 

Elastic  Constriction  of  Limb. 

Simple  elastic  constriction  of  the  limb  without  the  use  of  a  rubber  band- 
age, when  properly  applied,  forms  a  safe  and  reliable  method  for  controll- 
ing hemorrhage,  and  may  be  applied  with  good  results  in  hemorrhage  fol- 
lowing injury  and  in  operative  procedures. 

Care  should  be  taken  in  such  cases  to  elevate  the  limb  before  applying 


Figure  638.    Showing  Application  of  Esmarch's  Elastic  Bandage  with  Cord  and  Chain. 

the  constrictor,  that  the  blood-vessels  may  be,  as  far  as  possible,  emptied  of 
their  contents  by  gravity. 

The  best  form  of  constrictor  is  Esmarch's  tourniquet,  or  flat  rubber 
band,  ordinarily  employed  in  connection  with  the  elastic  bandage.  When 
applied,  the  space  covered  by  the  constrictor  should  be  at  least  inches  in 
width,  care  being  taken  that  the  skin  does  not  bulge  outward  between  the 
turns  of  the  rubber  band.  The  application  should  be  made  while  the  limb 
is  in  a  vertical  position,  the  bandage  being  applied  quickly  and  firmly,  in 
order  to  simultaneously  arrest  both  venous  and  arterial  circulation. 

Good  results  may  also  be  obtained  by  the  use  of  a  piece  of  common  rub- 
ber tubing  of  from  ^  to  ^  inch  in  internal  diameter.  Two  to  four  turns 
may  be  made  quickly  around  the  limb  with  such  a  tube,  the  tubing  tied  in 
an  ordinary  reef  knot,  the  precautions  before  mentioned  being  employed. 


292  MINOR  OPERATIVE  SURGERY. 

In  the  absence  of  all  of  these  appliances,  a  pair  of  elastic  suspenders  may  be 
used  or  a  large  marble  or  pebble  the  size  of  a  small  hen's  egg  may  be  wrap- 
ped in  the  center  of  a  pocket  handkerchief,  the  ends  of  the  latter  tied 
around  the  limb  and  the  bandage  tightly  twisted  with  a  stick,  care  being 
taken  to  adjust  the  pebble  or  marble  so  that  it  rests  over  the  vessel  to  be 
compressed,  and  to  place  a  piece  of  heavy  card-board  or  leather  under  the 
knot  and  thus  avoid  pinching  the  skin. 

A  form  of  circular  constrictor,  shown  in  connection  with  the  elastic 
bandage  by  figure  637,  has  been  previously  described. 

Arterial  Compression. 

This  consists  in  controlling  the  circulation  by  compressing  the  artery 
which  supplies  the  part.  The  instruments  employed  for  this  purpose  are 
usually  called  tourniquets.  In  former  years,  the  use  of  these  appliances  was 


Figure  639.    Petit's  Tourniquet.  Figure  040.    Signproni's  Femoral 

Tourniquet. 

thought  indispensable  in  every  operation  upon  the  extremities.  At  this 
time  their  general  use  has  been  discontinued,  and  surgeons  usually  confine 
themselves  to  the  simple  rubber  band  or  cord  illustrated  in  connection  with 
Esmarch's  bandage  by  figures  637  and  638,  if  they  employ  a  tourniquet  at  all. 
One  or  the  other  of  these  devices  will  supply  a  tourniquet  in  its  most  simple 
and  efficient  form.  No  special  anatomical  knowledge  is  necessary  in  its 
application,  as  it  is  necessary  only  to  stretch  it  tightly  around  the  limb  above 
the  seat  of  operation  or  injury  and  fasten  it  with  the  hook  and  chain. 

Petit's  Tourniquet,  as  illustrated  in  figure  639,  consists  of  a  strong  band 
of  non-elastic  tape  passing  over  suitable  rollers  and  controlled  by  a  screw 
device.  Before  applying  this  tourniquet,  the  limb  should  be  protected  by 
surrounding  the  surface  to  be  included  within  the  band  with  a  few  turns  of 
roller  bandage,  to  protect  the  skin  from  pressure  and  to  avoid  crimping  or 
pinching,  which,  if  permitted  by  the  tightening  of  the  tourniquet  might 
produce  linear  constriction.  The  bandage  for  this  purpose  should  be  of 
sufficient  length  to  supply  the  turns  above  referred  to,  and  to  leave  a  remain- 
der that  may  be  utilized  as  a  compress  to  be  placed  over  the  artery  or  vein 
to  be  controlled.  When  applied,  the  base  of  the  instrument  should  be  placed 
on  the  compress  and  the  strap  buckled  on  the  outside  of  the  limb,  after 
which  any  amount  of  pressure  desired  may  be  obtained  by  turning  the 
screw,  thus  drawing  upon  the  bands  which  surround  the  limb.  Care  should 


ARTERIAL    COMPRESSION. 


293 


be  taken  to  see  that  a  few  inches  of  the  tape  lie  between  the  clamp  and  the 
buckle,  otherwise  the  action  of  the  screw  may  be  interfered  with. 

Signoroni's  Femoral  Tourniquet,  as  shown  by  figure  640,  is  employed 
only  for  compression  of  the  femoral  artery.  It  consists  of  a  horseshoe- 
shaped  clamp,  hinged  at  its  center,  and  regulated  by  a  threaded  screw. 
One  end  of  the  bar  terminates  in  a  pad  with  a  well-rounded  surface  for  com- 
pressing the  artery.  The  other  end  terminates  in  a  longer  and  broader 
pad  of  sufficient  size  to  furnish  the  necessary  counter-pressure.  It  is  usually 
applied  by  placing  the  small  pad  over  the  femoral  artery  at  the  groin,  with 
the  larger  one  beneath  the  tuberosity  of  the  ischium. 

Lister's  Abdominal  Aorta  Tourniquet,  as  outlined  in  figure  642,  consists 
of  a  U-shaped  steel  bar,  to  the  inner  surface  of  the  lower  extremity  of 
which  a  fixed  pad  about  3  inches  in  diameter  is  secured.  A  long  screw 


Figure  G41.    Esmarch's  Emergency  Tourniquet. 


Figure  643.    Lister's  Abdominal  Aorta 
Tourniquet. 


bolt  with  a  T-shaped  head  passes  through  the  upper  extremity,  the  lower 
end  being  padded. 

This  instrument  is  intended  particularly  for  compressing  the  abdominal 
aorta.  It  should  be  applied  upon  the  right  side  of  the  patient,  care  being 
taken  that  it  does  not  slip  off  from  the  fourth  lumbar  vertebra.  No  more 
force  should  be  applied  than  that  sufficient  to  interrupt  the  circulation. 

Esmarch's  Emergency  Tourniquet,  as  detailed  in  figure  641,  answers  in 
some  cases  as  well  as  the  more  complicated  and  expensive  patterns,  although 
care  must  be  taken  in  its  application  to  prevent  linear  constriction. 

It  consists  of  a  hard-rubber  artery  pad  with  about  one  square  inch  of 
bearing  surface,  provided  with  an  opening  through  which  passes  an  elastic 
cord  or  constrictor  about  %  inch  in  diameter  and  2  to  3  feet  in 
length.  Immediately  above  this  opening  is  a  second  one  of  the  same  size, 
but  connected  with  the  upper  or  outer  surface  by  a  narrow  groove,  as  shown 
in  the  illustration.  It  is  applied  by  placing  the  pad  over  the  artery  to  be 
compressed,  passing  the  cords,  tightly  drawn,  around  the  limb  in  opposite 
directions,  after  which,  while  stretched,  the  cords  are  forced,  one  at  a  time, 
through  the  groove  into  the  same  opening  where,  when  the  stretching  force 
is  removed,  they  will  remain  until  released.  This  device,  complete,  weighs 
less  than  an  ounce,  and  is  so  small  it  can  easily  be  carried  in  the  pocket, 
emergency  or  small  instrument  bag.  It  will  be  found  useful  in  street  and 


294  MINOR    OPERATIVE    SURGERY. 

railway  injuries,  gunshot  wounds,  etc.     It  should  be  applied  over  a  roller 
bandage,  underclothing  or  other  suitable  fabric. 

Davy's  Lever,  as  shown  in  figure  643,  consists  of  a  rigid  rod  about  twenty 
inches  in  length  provided  witfr  a  handle,  its  distal  end  enlarged  in 
cylindrical  form.  It  is  of  such  size  and  shape  that  when  passed  through  the 
sphincter  and  along  the  rectum  it  may  be  used  to  compress  the  common  iliac 
artery  on  either  side.  Pressure  is  made  on  the  side  upon  which  the  oper- 
ation is  to  be  performed,  the  force  being  exerted  at  a  point  between  the  lum- 
bar vertebrae  and  psoas  magnus  muscle.  When  the  lever  is  in  position,  by 


Figure  643.    Davy's  Lever. 

slowly  raising  the  handle,  with  a  gentle,  firm  pressure,  sufficient  force  may 
be  imparted  to  the  fulcrum  end  to  control  the  blood  flow.  About  two  ounces 
of  sweet  oil  should  be  injected  previous  to  the  introduction  of  the  lever. 

Forcipressure. 

Forcipressure  is  a  term  applied  to  the  immediate  closing  of  a  bleeding 
vessel  by  the  direct  application  of  a  suitable  forceps.  A  force  should  be 
employed  sufficient  to  crush  the  inner  coat  of  the  artery  or  vein  and  secure 
instantaneous  hemostasis. 

The  crushed  vessels  are  not  only  completely  closed  by  his  method,  but 
smaller  ones  are  permanently  sealed  by  the  blood  coagulation  which  neces- 
sarily follows. 

Hemostatic  forceps,  like  their  obstetrical  namesakes,  can  be  purchased 
in  a  seemingly  endless  variety.  In  many  cases,  the  difference  between  them 
is  so  slight  as  to  be  almost  undistinguishable  by  any  except  those  who 
have  invented  or  modified  them.  For  general  use  they  usually  pos- 
sess strong,  blunt  jaws,  the  engaging  or  crushing  surfaces  of  which  are  pro- 
vided with  either  transversely  serrated  teeth,  as  in  the  design  of  Pean,  the 


Figure  644.    "A"  showing  Forceps  with  Perfect  Serrations;     "  B  "  showing  Imperfect  or 

Mismatched  Serrations. 

interlacing  toothed  pattern  as  in  the  bull-dog  forceps,  or  a  combination  of 
both,  as  exhibited  in  the  forceps  of  Kocher. 

Every  surgeon  should  provide  himself  with  a  liberal  quantity  of  hemo- 
static  forceps;  in  fact,  no  extensive  operation  should  be  undertaken  without 
having  from  one  to  two  dozen,  aseptic  and  ready  for  use.  They  are  re- 
quired not  only  for  controlling  hemorrhage,  but  for  holding  sutures,  tampons 
and  drainage  tubes  and  for  other  miscellaneous  work,  as,  for  example,  clos- 
ing the  rubber  tube  of  an  irrigator.  Occasionally  they  will  get  out  of  order, 
and  not  infrequently  one  or  more  are  rendered  "out  of  action"  by  being 
dropped  upon  the  floor  or  otherwise  brought  into  contact  with  septic  sub- 
stances. 

Care  should  be  exercised  in  their  selection  to  see  that  they  are  properly 
shaped  and  tempered.  The  jaws  should  be  so  constructed  that  when  closed, 
the  serrated  or  toothed  surfaces  will  "mesh"  as  do  the  cogs  in  a  set  of  gear 
wheels. 

The  imperfect  condition,  manifest  in  figure  644,  may  be  the  result  of 


FORC1PRESSUKE. 


295 


careless  workmanship  or  may  be  due  to  the  mismatching  of  separate  blades 
by  the  assistant  .during  or  following  cleaning  and  sterilizing.  The  dangers 
incurred  by  the  use  of  such  "misfit"  pairs  and  the  loss  of  time  necessitated 
in  selecting  "mates"  may  be  obviated  by  attaching  a  plain  key  ring  to  one 
part  of  each  forceps.  When  the  blades  are  separated  for  cleaning,  the  mate 


Figure  045.    Showing  Forcep  Blades  United  for  Sterilizing. 

may  be  snapped  into  the  key  ring  and  the  two  parts  thus  kept  together  un- 
til wanted  for  use.  Short  pieces  of  fine  copper  wire  may  be  kept  in  readi- 
ness and  employed  instead  of  the  key  rings,  or  thread  may  be  substituted, 
tying  the  blades  together  and  cutting  the  loops  with  scissors  when  uniting 
the  blades  for  use. 

Mechanically,  hemostatic  forceps  may  be  divided  into  four  classes,  snap- 
catch,  slide-catch,  spring-catch  and  self-closing. 


Figure  646.    Showing  Properly  and  Improperly  Constructed  Hemostatic  Forceps. 

Snap-Catch  Hemostatic  Forceps  is  a  term  employed  to  designate  that 
class  of  scissor  handle  artery  forceps  which  is  provided  with  a  ratchet  catch 
in  the  handles  and  so  adjusted  that  they  will  lock  automatically  by  closure 
of  the  handles. 

This  pattern  is  more  generally  used,  because,  as  they  are  of  the  scissor 
handle  variety,  they  not  only  afford  a  better  and  safer  grip,  but  they  may  be 
employed  for  many  purposes  other  than  con  trolling  hemorrhage.  They  may 


Figure  647.    Halsted's  Plain  Hemostatic  Forceps. 

be  used  for  holding  needles,  removing  polypi,  packing  or  plugging  wounds 
or  cavities,  grasping  small  masses,  removing  dressings,  etc. ;  in  fact,  they 
are  as  useful  to  the  surgeon  as  is  a  jack-knife  to  the  carpenter.  They  can  be 
attached  or  removed  almost  instantly.  They  afford  a  firm  grip  and  owing 
to  the  weight  of  the  handle  end,  it  is  easy  to  keep  them  out  of  the  way  of' the 
operator.  When  lightly  closed,  only  the  points  or  tips  of  the  jaws  should 
touch.  As  pressure  on  the  handles  is  gradually  exerted,  the  central  and  rear 


296  MINOR    OPERATIVE    SURGERY. 

spaces  between  the  blades  should  close  until  all  the  serrations  are  brought 
into  actual  contact.  A  forceps  of  faulty  construction  when  tightly  closed 
may  open  at  the  extreme  end  and  thus  prove  worthless. 

This  disadvantage  is  shown  by  figure  646.  If  a  blood-vessel  be  grasped 
with  the  points  of  such  a  forceps,  the  more  tightly  the  handles  are  pressed, 
the  less  will  be  the  force  exerted  on  the  bleeding  surface. 

Snap-catch  hemostatic  forceps  may  usually  be  found  in  four  varieties  of 
jaws;  plain,  serrated,  mouse-toothed,  and  combined  serrated  and  mouse- 
toothed. 


Figure  648.    P6an's  Hemostatic  Forceps. 


Halsted's  Plain  Hemostatic  Forceps,  as  described  by  figure  647,  are  con- 
structed with  smooth  contact  surfaces.  They  are  particularly  adapted  for 
grasping  large  masses  of  tissue,  not  only  where  minute  vessels  are  obscured, 
but  in  cases  of  parenchymatous  oozing.  They  are  also  useful  in  such  oper- 
ations as  breast  amputations,  where  temporary  compression  of  small  vessels 
is  desirable. 

Pean's  Hemostatic  Forceps,  as  pictured  in  figure  648,  is  probably  the 
oldest  and  certainly  the  best  known  forceps  of  this  pattern.  Compared 
with  other  forceps  of  this  class,  they  are  of  light  construction,  and  as  the  dis- 
tance from  the  pivot  or  fulcrum  to  the  jaw  represents  at  least  one-third  of 


Figure  649.    Spencer  Wells  Hemostatic  Forceps. 

the  entire  length  of  the  instrument,  they  are  not  adapted  for  cases  where 
great  force  is  required.  The  locks  are  provided  with  two  or  more  catches, 
that  different  degrees  of  pressure  may  be  obtained.  Occasionally  the  jaws  are 
manufactured  with  additional  oblique  and  longitudinal  grooves  with  a  view 
of  employing  the  instrument  for  needle  or  pin-holding  purposes.  As  they 
are  not  strong  enough  in  construction  to  be  used  for  this  purpose,  this  addi- 
tion is  of  little  value.  The  regular  size  is  4^  inches  in  length,  although 
they  can  be  procured  in  lengths  of  5  and  5^  inches. 


FORCIPRESSURE. 


297 


Spencer  Wells'  Hemostatic  Forceps,  as  delineated  in  figure  649,  differ 
from  the  pattern  of  Pean  last  described  in  being  of  heavier  construc- 
tion and  with  shorter  jaws  The  blade  is  broader,  while  the  rings  of  the 
handles  are  constructed  with  obliquely  turned  inner  faces,  that  they  may 
better  fit  the  thumb  and  finger  of  the  operator.  Their  usual  length  is  4^ 
inches. 

Tait's  Hemostatic  Forceps,  as  traced  in  figure  650,  bear  about  the  same 
relation  to  the  pattern  of  Spencer  Wells  that  the  latter  does  to  that  of  Pean. 
It  is  constructed  upon  nearly  the  same  lines  as  that  of  Spencer  Wells,  but 
much  heavier  and  with  a  more  bulbous  jaw.  The  latter  is  particularly 
adapted  to  the  ligation  of  vessels.  When  used  for  this  purpose,  the  suture 


Figure  C50.    Tait's  Hemostatic  Forceps. 

may  first  be  tied  loosely  around  the  forceps  bulb,'  after  which  it  may,  with 
ease,  be  slipped  over  the  vessel  to  be  ligated.  As  it  is  much  heavier 
than  either  of  the  previously  described  patterns,  it  is  more  popular  with 
operators  who  require  a  firm  and  strong  instrument.  The  usual  length  is 
4^/2  inches. 

Tait's  Curved  Hemostatic  Forceps,  as  sketched  in  figure  651,  though 
generally  accredited  to  Tait  were,  we  believe,  originally  of  German  design. 
They  differ  from  the  pattern  of  the  former  in  being  constructed  with  a  jaw  less 
bulbous  in  form  and  curved.  They  have  been  largely  employed  in  rectal 


Figure  651.    Tait's  Curved  Hemostatic  Forceps. 

surgery  where  the  curved  shape  is  found  advantageous,  as  the  handles  of  the 
instrument  after  application  may  the  more  easily  be  turned  out  of  the  field 
of  vision.  The  usual  length  is  4^  inches. 

Halsted's  Straight  Artery  Forceps,  as  exhibited  by  figure  652,  differ 
from  the  pattern  of  Tait  in  being  constructed  with  more  conical  jaws,  ter- 
minating in  fine  points.  The  serrations  are  much  finer  and  extend  from  the 
point  backward  about  one-half  the  length  of  the  forceps  jaws.  This  form 
enables  the  operator  to  grasp  an  artery  alone  or  to  confine  the  enclosed  mass 
to  small  masses  of  tissue  in  cases  where  ligation  is  necessary.  They  are 


298 


MINOR    OPERATIVE    SURGERY. 


also  advantageous  for  work  in  dense  or  cicatricial  tissue  because  with  them 
a  mass  may  be  penetrated,  which  can  not  be  accomplished  with  blunt- 
pointed  forceps. 

Dudley's  Hemostatic  Forceps,  as  expressed  in  figure  653,  are  of  the  Spen- 
cer Wells'  type,  but  the  jaws  are  longer  and  more  slender,  the  usual  length 
of  the  serrated  surface  being  about  seven-eights  of  an  inch,  the  entire 
length  of  the  forceps  being  5  inches. 

Ferguson's  Hemostatic  Forceps,  as  depicted  in  figure  654,  present  a  sharp 
and  well-defined  crushing  surface  operated  by  handles  of  more  than  ordi- 
nary strength.  The  narrow  shape  and  extreme  vertical  width  of  the  jaws 
afford  the  greatest  amount  of  power  consistent  with  the  length  of  the 


Figure  652.    Halsted's  Straight  Artery  Forceps. 

instrument.  As  they  are  constructed  with  a  narrow  lateral  surface,  they 
occupy  but  little  space  in  a  wound  and  shut  out  only  a  small  amount  of 
tissue  from  view. 

The  extensive  serrated  surface  enables  the  operator  to  grasp  not  only 
the  bleeding  artery,  but  the  surrounding  tissues,  while  the  narrow  bite  of 
the  jaws  permits  the  holding  of  a  small  vessel. 

The  ends  are  blunt  to  facilitate  ligation,  as  a  thread  may  easily  be 
slipped  over  the  end  of  the  forceps.  In  their  general  construction  all  angles 


Figure  653.    Dudley's  Hemostatic  Forceps. 


They 


are  avoided,  smooth,  rounded  surfaces  being  presented  at  all  points, 
may  be  procured  in  lengths  of  4^,  5^5,  6%  and  7^  inches. 

Etheridge's  Hemostatic  Forceps,  as  portrayed  in  figure  655,  are  con- 
structed with  long  and  somewhat  slender  jaws.  This  renders  them  ap- 
plicable in  cases  where  there  is  oozing  of  blood  from  extended  surfaces,  and 
where  it  is  desired  to  include  a  mass  of  tissue  in  the  grasp  of  the  instru- 


FORCIPRESSURE. 


299 


ment.  This  forceps  may  not  only  be  used  as  a  hemostatic  agent,  but  for 
the  Removal  of  polypi,  for  dilating  sinuses  or  other  small  openings,  etc. 
The  usual  length  is  4^  inches,  but  special  sizes,  6  and  8  inches  in  length, 
are  constructed  for  abdominal  and  gynecological  use. 

Thornton's  T-shaped  Hemostatic  Forceps,  as  depicted  in  figure  656,  are 


Figure  654.     Ferguson's  Hemostatic  Forceps. 


applicable  only  in  special  cases.  Usually  they  are  of  heavy  construction,  the 
jaw  being  at  right  angles  to  the  axis  of  the  instrument.  They  will  be 
found  useful  in  cases  where  it  is  desired  to  grasp  a  large  surface  with  a 
single  instrument,  as  in  capillary  and  parenchymatous  hemorrhage. 
Occasionally  they  may  be  found  useful  in  abdominal  surgery,  where  it  is 


Figure  655.    Etheridge's  Hemostatic  Forceps. 

necessary  to  hold  the  broad  ends  of  severed  tissues,  to  retain  a  part  of  the 
omentum  while  being  sutured,  or  to  close  a  wound  in  some  hollow  viscus 
or  cyst. 

Little's  Hemostatic  Forceps,  as  shown  in  figure  657,  are  an  improvement 
over  the  bull-dog  pattern  of  spring  catch  forceps  that  formed  for  so  many 


Figure  656.    Thornton's  "T"-Shaped  Hemostatic  Forceps. 

years  one  of  the  standard  hemostatics.  The  handle  construction  is  the  same 
as  that  of  the  Pean  type,  while  it  possesses  all  the  advantages  of  the  bull- 
dog jaw.  They  are  particularly  adapted  to  securing  small  superficial  vessels 


300 


MINOR    OPERATIVE    SURGERY. 


where  accurate  adaptation  is  necessary.     They  are  usually  4^  inches  in 
length. 

Kocher's  Hemostatic  Forceps,  as  pictured  in  figure  658,  sometimes 
known  as  Semi's,  combine  many  of  the  better  qualities  of  several  patterns 
previously  described.  They  possess  the  artery  crushing  powers  of  the 


Figure  657.    Little's  Hemostatic  Forceps. 


serrated  designs  and  the  fine  adaptation  of  the  mouse-toothed  variety. 
Owing  to  their  special  form  there  is  little  risk  of  their  slipping  from  en- 
gaged tissues.  Their  construction  is  sufficiently  heavy  for  any  required 
purpose.  They  are  usually  manufactured  in  two  lengths,  4}^  and  5  inches. 
Pratt's  Short  Hemostatic  Forceps,  as  is  apparent  in  figure  659,  have 


Figure  658.    Kocher's  Hemostatic  Forceps. 


short  curved  jaws,  transversely  serrated,  one  terminating  in  two,  the  other 
in  three  mouse-teeth,  closely  matched.  The  curve  of  the  blade  is  such  that 
when  applied  to  a  superficial  wound,  the  handle  may  rest  flat  upon  the 
surrounding  surface.  This  is  said  to  be  an  advantage  in  many  operations. 


Figure  659.    Pratt's  Short  Hemostatic  Forceps. 


Ordinarily  they  are  4^  inches  in  length,  a  special  size,  6  inches  long,  being 
occasionally  employed. 

Skene's  Hemostatic  Forceps,  as  imaged  in  figure   660,  are  constructed 
with  short,  transversely  serrated  jaws,  bent  downward  or  knee  bent  upon 


FORCIPRESSURE. 


301 


the  edge.       The  jaws  terminate  in  teeth  similar  to  the  pattern  of  Kocher 
before  described.     Owing  to  the  shape  of  this  instrument  it  is  adapted  for 


use  in  cavities  where  it  is  desirable  that  the  handle  of  the  instrument 
should  be  outside  the  line  of  vision.  Its  length  is  4^  inches. 

Slide-Catch  Artery  Forceps  embrace  such  spring  artery  forceps  as  are 
held  closed  by  means  of  a  sliding  catch. 

Charrierre's  Hemostatic  Forceps,  as  disclosed   in   figure   66 1,    represent 


Figure  661.     Charrierre's  Hemostatic  Forceps. 


one  of  the  oldest  patterns  still  in  use.  Nearly,  if  not  all  the  modern  types 
of  slide  catch  forceps  are  modifications  of  this  design.  The  length  is  4  y2 
inches,  and  the  jaws  are  sharply  serrated 

Fricke's   Hemostatic  Forceps,  as  portrayed  by  figure    662,    differ   but 


Figure  662.    Fricke's  Hemostatic  Forceps. 


little  from  the  Charrierre  pattern,  except  in  their  separable  qualities.  The 
blades  are  not  only  easily  unlocked,  but  the  slide-catch  can  be  removed  for 
cleaning.  The  regular  lengths  are  4^  and  5^  inches. 

Andrews'   Hemostatic  Forceps,  as   illustrated  in  figure  663,  differ  from 




Figure  663.    Andrews'  Hemostatic  Forceps. 


that  of  Fricke,  only  in  the  shape  of  the  blade  tips,  which  are  of  the  bulbous 
type,  the  better  to  facilitate  the  slipping  downward  of  a  ligature  knot. 
The  jaws  are  small  enough  to  enable  them  to  pass  under  the  loop  of  an 
ordinary  pocket  case.  The  blades  are  separable  to  facilitate  cleansing  and 
disinfection.  Their  usual  length  is  4^  inches. 


Figure  664.     Luer's  Hemostatic  and  Ligating  Forceps. 

Luer's  Hemostatic  Forceps,  as  delineated  in  figure  664,  are  broader  and 
heavier  than  most  other  patterns  of  this  type.     The  jaws  are  full  and  bulbous 


IE 


302 


MINOR    OPERATIVE    SURGERY. 


shaped,  thus  rendering  this  a  desirable  form  for  the  libation  of  vessels. 
The  forceps  is  4^  inches  in  length  and  the  catch  removable  for  cleaning. 

The  Bull-Dog  Hemostatic  Forceps  and  Needle  Holder,  as  set  forth  in 
figure  665,  is  a  combination  of  the  well-known  bull-dog  artery  forceps  with 
a  small  needle  holder.  As  an  artery  forceps  it  is  useful  for  engaging  the 


Figure  665.    Bull-Dog  Hemostatic  Forceps  and  Needle  Holder. 

smaller  vessels,  particularly  where  accurate  adjustment  is  required,  while  its 
bulbous  jaws  make  it  desirable  for  ligation.  As  a  needle  holder,  while  it 
will  hold  small  needles,  it  does  not  present  sufficient  grasping  surface  or 
power  to  hold  the  larger  ones.  When  stitching  by  hand  with  large  needles, 
this  forceps  may  be  used  to  grasp  the  needle  points  as  they  protrude  through 
the  integument,  in  case  they  do  not  project  far  enough  to  furnish  a  firm 
grip  for  the  fingers.  The  length  is  4^  inches. 

Spring-Catch  Hemostatic  Forceps  include  those  artery  forceps  that  are 
constructed  with  a  self-acting  spring  by  which  the  handles  will  remain 
locked  until  the  spring  is  released. 

Liston's  Hemostatic  Forceps,  as  illustrated  in  figure  666,  are  among  the 
oldest  spring  catch  forceps  that  still  command  a  limited  use.  They  are  mouse- 


.  Figure  666.    Listen's  Hemostatic  Forceps. 

toothed  and  their  points  are  so  slender  that  they  are  available  in  operations 
about  the  eye  and  other  parts  of  the  face  where  accurate  adjustment  is 
necessary.  The  length  is  4^  inches. 


Figure  667.    Maclean's  Hemostatic  Forceps. 

Maclean's  Hemostatic  Forceps,  as  shown  by  figure  667,  are  -much  heavier 
than  the  pattern  of  Listen.  They  are  provided  with  five  teeth  and  are  thus 
better  suited  for  use  as  tissue  forceps.  The  length  is  4^  inches. 

Self-Closing  Artery  Forceps,  as  the  name  implies,  require  no  force  for 
closing.  The  grasp  is  released  by  firm  pressure  on  the  blades. 

The  Plain  Self-Grasping  Artery  Forceps,  traced  in  figure  668,  are  of  the 


Figure  668.    Plain  Self-Grasping  Artery  Forceps. 


' '  Bull-dog"  type.  Owing  to  their  self -grasping  power,  they  require  no  further 
attention  after  engagement  with  the  tissues.     The  length  is  4^  inches. 

1 0    5  fj  5  J  J  0  0 


TORSION. 


303 


The  Wire  Serresfins,  represented  by  figures  669  and  670,  are  hemostatic 
forceps  in  their  most  inexpensive  style.       They  are  manufactured  from 


Figure  669.    Straight  Wire  Serresfins. 


Figure  670.    Curved  Wire  Serresfins. 


spring  wire,  the  terminal  points  of  which  are  flattened  and  shaped  in  mouse- 
tooth  form.  They  possess  no  special  merit,  excepting  that  of  a  low  price. 
The  Steel  Serresfins,  described  by  figures  671  and  672,  have  quite  an 
extensive  sale  because  of  their  low  price  and  compact  form.  They  are  so 
small  as  to  be  out  of  the  way  in  many  operations,  and  for  this  reason  they 


Figure  671.    Langenbeck's  Curved  Serresfins. 


Figure  672.    Jointed  Serresfins. 


are  valuable  to  a  surgeon  when  operating  either  alone  or  with  a  single 
assistant.  A  limited  number  should  be  included  in  each  pocket  emergency 
outfit.  Their  length  is  from  2  to  2^  inches. 

Franks'  Hemostatic  Scalp  Clamp,  as  depicted  in  figure  673,  is  self-clos- 
ing in  "T"  form.  The  inner  margins  are  serrated  and  one  jaw  is  provided 
with  three  short  and  sharp  teeth,  which  project  through  openings  in  the 
opposite  jaw  when  the  forceps  is  closed.  It  is  employed  in  operations  on 
the  skull  to  prevent  hemorrhage  by  compression.  It  is  intended  to  include 
the  entire  thickness  of  the  flap  in  the  bite  of  the  instrument.  In  operations 

I 

! 

i 

Figure  673.    Franks'  Hemostatic  Scalp  Clamp. 

on  the  skull  the  vessels  are  necessarily  cut  flush  with  the  wound  margin. 
This  affords  little  opportunity  for  grasping  any  bleeding  vessels.  An  ordi- 
nary hemostatic  forceps  crushes  all  grasped  tissues.  The  instrument  here 
described  acts  as  an  effectual  compressor  besides  serving  the  purpose  of  a 
retractor  without  injury  to  the  tissues. 

Torsion. 

Torsion  consists  in  seizing  and  twisting  the  proximal  end  of  a  severed 
artery  until  its  resistance  is  completely  overcome.  Torsion  can  usually  be 
best  accomplished  by  grasping  the  vessel  about  half  an  inch  from  its  severed 
end  with  a  second  forceps  and  holding  it  with  this  during  the  continuance 
of  the  twisting  process. 

Care  should  be  taken  to  grasp  the  artery  entire,  for  if  only  a  part  of  the 
vessel  be  seized,  or  if  only  one  blade  be  introduced  into  the  open  end  of 


304 


MINOR  OPERATIVE  SURGERY. 


the  vessel,  the  part  included  in  the  forceps  jaw  may  be  twisted  off  and  an 
imperfect  result  follow.  While  a  snap-catch  forceps  can  be  successfully 
used  for  this  purpose,  the  slide-catch  patterns  are  usually  preferred.  The 


Figure  674.    Author's  Slide  Catch  Torsion  Forceps. 

width  of  the  forceps  blade  selected  must  depend  somewhat  on  the  size  of 
the  artery  to  be  twisted ;  one  a  trifle  longer  in  the  jaw  than  the  width  of 
the  flattened  vessel  being  preferred.  As  slide-catch  forceps  are  more  fre- 
quently used  as  forcipressure  instruments,  we  illustrate  all  but  one  pattern 
under  that  head. 

The  Author's  Torsion  Forceps,  as  illustrated  in  figure  674,  combine  the 
best  qualities  of  two  or  three  previously  described  designs.  The  jaws 
besides,  being  serrated,  terminate  in  several  mouse-teeth,  thus  preventing 
the  forceps  from  slipping  off  from  the  engaged  tissues.  The  slide  is 
arranged  to  adjust  the  grasp  to  different  degrees  of  tension  and  to  various 
thicknesses  of  tissue.  These  advantages  render  it  particularly  useful  for 
torsion.  Its  length  is  5  inches,  and  its  parts  are  separable  for  cleaning. 

Ligation. 

Various  causes  necessitate  the  use  of  a  ligature  to  control  hemorrhage 
or  decrease  the  blood  supply.  A  vessel  may  be  severed,  ruptured  or  dilated 
(aneurysm),  or  it  may  require  complete  or  partial  closure  in  its  continuity. 
The  ligatures  employed  are  usually  absorbable  that  they  may  prove  no 
obstacle  in  the  way  of  securing  primary  wound  union. 


Figure  675.     Bull-Dog  Artery  Forceps. 

During  an  operation  small  severed  vessels  may  be  ligated  by  means  of 
artery  forceps.  This  may  be  done  primarily  or  after  it  is  found  that  closure 
by  forcipressure  or  torsion  is  either  incomplete  or  unsafe.  In  such  cases 


Figure  676.    Bulbous  Ligating  Forceps. 


the  vessel  is  grasped  by  the  forceps,  the  ligature  tied  around  the  forceps 
with  a  single  knot,  after  which  it  may  be  slipped  down  upon  the  vessel  and 
the  tying  completed. 

The  Bull-Dog    Artery    Forceps,  drawn    in   figure    675,   are  particularly 
designed  for  engaging  and  closing  smaller  vessels  and  for  grasping  the 


LIGATION. 


305 


larger  arteries  preliminary  to  ligation,  its  well-rounded  or  expanded  jaws 
adapting  it  to  this  work.  It  is  useful  in  tying  deep-seated  arteries,  such  as 
are  encountered  in  the  interosseous  spaces. 

The  Bulbous  Ligating  Forceps,  shown  by  figure  676,  is  one  of  the  largest 
and  strongest  of  this  class,  and  may  be  used  for  grasping  the  large  as  well 
as  small  vessels.  Its  special  form  renders  it  useful  where  ligation  must 
follow  the  application  of  a  forceps.  Its  grasping  surface  combines  the  ser- 
rated and  mouse-tooth  patterns.  While  ligation  may  be  safely  accomplished 
with  an  ordinary  artery  forceps,  those  with  bulbous  or  expanded  jaws  are 
generally  preferred.  The  length  of  the  forceps  shown  in  the  illustration  is 
5  inches. 

Operative  Ligation. 

In  addition  to  the  minor  operating  instruments  specified  on  pages  271  to 
276,  this  procedure  will  require  a  tenaculum,  an  aneurysm  ligature  carrier 
and  ligatures. 

The  ligatures  necessary  for  this  procedure  will  be  found  described  on 
pages  318  to  322. 

Minor  Operating  Tenacula  are  used  in  ligation  to  separate  blood-vessels 
from  surrounding  parts  and  draw  them  away  from  the  soft  tissues.  The 
curve  should  be  large  and  somewhat  flattened  upon  its  outer  side  that  the 
instrument  may  be  easily  detached  from  any  engaged  tissues. 

The  Minor  Operating  Tenaculum,  as  displayed  by  figure  677,  represents 
the  ordinary  pattern.  Full- sized  illustrations  of  handles  and  hooks  will  be 
found  on  page  278. 

Aneurysm  Ligature  Carriers  are  slender,  curved,  blunt-pointed  instru- 
ments, employed  for  passing  or  carrying  ligatures  around  vessels  to  be  con- 


Figure  677.    Minor  Operating  Tenaculum. 

trolled.  As  the  points  of  these  instruments  are  usually  well  rounded,  they 
may  often  be  employed  to  aid  in  the  separation  of  the  vein  or  artery  from 
surrounding  tissues. 

The  Aneurysm  Ligature  Carrier,  illustrated  by  figure  678,  represents  the 
regular  form,  such  as  may  be  procured  with  the  style  of  handle  shown  on 
page  275. 


Figure  678.    Aneurysm  Ligature  Carrier. 


The  Aneurysm  Ligature  Carrier  and  Director,  as  shown  by  figure  679,  is  an 
economical  form  of  this  instrument.     Its  principal  advantage  is  its  adapta- 


Figure  679.    Aneurysm  Ligature  Carrier  and  Director. 


bility  to  a  pocket  case.     Its  length  is  4^  inches.     Its  use  as  a  director  is 
described  on  page  287. 
20 


306  MINOR    OPERATIVE    SURGERY. 

Acupressure. 

This  consists  in  compressing  a  vessel  by  means  of  the  elastic  force  or 
spring  exerted  by  a  tempered  needle  when  forcibly  curved.  This  method 
is  adapted  to  cases  where  the  vessel  can  not  be  seized,  or  is  thought  too 
friable  to  be  ligated.  Needles  for  this  purpose  may  be  plain  or  in  forceps 
form. 

Direct  compression  may  be  made  by  forcing  a  needle  through  any  over- 
lying tissues,  passing  it  under  and  against  the  vessel  and  out  upon  the 
opposite  side,  its  course  being  so  changed  where  it  passes  under  the  artery 
as  to  press  firmly  against  the  latter. 


Figure  680.    Acupressure  Needles  with  Glass  Heads. 

The  Acupressure  Needles,  portrayed  in  figure  680,  may  be  manufactured 
of  gold,  silver  or  steel,  with  glass  or  ring  heads.  Those  of  steel  with 
glass  heads  are  usually  preferred.  Their  lengths  are  2^,3,  3^  and  4 
inches. 

Wyeth's  Needle,  as  shown  by  figure  681,  consists  of  a  large  steel  skewer 
with  sharp  slender  point  and  round  head.  It  is  employed  for  trans- 


Figure  681.    Wyeth's  Acupressure  Needle  for  Bloodless  Amputation  at  the 
Shoulder  or  Hip  Joint. 

fixing  the  deeper  muscles  and  fascia  in  the  same  manner  as  that  employed 
in  controlling  hemorrhage  by  ordinary  acupressure.  Strong  rubber  tubing 
is  wound  around  both  projecting  ends  of  the  needle  in  the  form  of  a  figure 
eight.  It  is  claimed  that  the  cumulative  pressure  produced  by  several 
strands  of  tubing  thus  applied  will  completely  close  all  blood-vessels  con- 


Figure  682.    Allis'  Hemostatic  and  Tenaculum  Figure  683.    Allis'  Hemostatic  Forceps. 

Forceps. 

tained  within  the  transfixed  mass.     The  use  of  these  needles  forms  the  basis 
of  what  is  sometimes  calledUWyeth'-s  bloodless  operation. 

Allis'  Acupressure  Forceps,  as  outlined  in  figure  682,  is  a  spring-handled 
instrument,  the  under  or  inferior  blade  of  which  is  needle-shaped,  terminat- 
ing in  a  sharp,  slender  point,  suitable  for  penetrating  or  transfixing  soft 
tissues. 


ACUPRESSURE,   COMPRESSES,   CAUTERIZATION.  307 

The  upper,  or  superior  blade,  presents  a  flattened  inner  surface,  similar 
to  that  employed  in  pressure  forceps.  This  instrument  is  used  to  control 
parenchymatous  hemorrhage  where  there  is  oozing  and  continuous  bleeding 
from  a  large  surface.  In  such  cases  the  needle  blade  should  be  forced 
through  the  tissue,  beneath  the  bleeding  parts,  and  the  forceps  turned,  so 
that  when  closed,  the  points  of  hemorrhage  will  be  included  within  the 
grasp  of  the  instrument.  They  may  also  be  used  in  cases  where  several 
small  vessels  in  close  connection  with  each  other  require  control  at  the  same 
time. 

One  advantage  that  these  instruments  possess  over  all  others,  lies  in  the 
fact  that  the  pressure  may  be  completely  released  without  withdrawing  the 
needle,  and  the  tendency  to  further  hemorrhage  ascertained.  If  bleeding 
has  ceased,  the  instrument  can  be  entirely  removed;  if  it  continues,  the 
pressure  may  be  again  resumed,  or  a  ligature  can  be  passed  around  the 
transfixing  needle. 

Another  advantage,  and  one  not  to  be  underrated,  is  that  it  does  not 
check  hemorrhage  by  crushing  or  destroying  tissues.  It  is,  as  the  name 
implies,  a  true  acupressure  forceps,  and  when  removed,  the  tissues  that 
have  been  enclosed  are  as  ready  and  well  suited  to  repair  as  any  part  of  the 
wound. 

The  Improved  Acupressure  Forceps,  as  represented  in  figure  684,  show 
a  later  pattern  with  graduated  catch,  the  original  model  being  de- 


Improved  Acupressure 
Forceps. 

signed  with  self-closing  blades.  As  the  amount  of  pressure  produced  by 
a  forceps  of  that  character  could  not  be  regulated,  the  pattern  here  shown 
has  been  adopted  in  its  stead.  It  may  be  procured  either  straight  or 
curved.  The  length  is  usually  about  4^/2  inches. 

Antiseptic  Compresses. 

Compresses  for  surgical  use  consist  of  pieces  of  gauze  or  other  fabric, 
folded  into  masses  of  such  size  that  by  bandage  pressure  or  other  force, 
they  may  not  only  absorb  escaping  blood,  but  by  pressure  on  the  bleeding 
vessel  may  also  assist  in  arresting  hemorrhage. 

They  form  a  ready  and  convenient  means  for  the  treatment  of  acci- 
dental hemorrhage,  such,  for  instance,  as  superficial  wounds,  open  or  lacer- 
ated. Several  prepared  packages  will  be  found  described  in  the  chapter 
devoted  to  Military  Surgery. 

Cauterization. 

The  use  of  the  cautery  as  a  hemostatic  agent  is  still  necessary  in  certain 
cases,  particularly  in  deep-seated  wounds,  the  stumps  of  tumors,  etc.  The 
various  appliances  required  are  fully  described  by  figures  397  to  400. 


308 


MINOR    OPERATIVE    SURGERY 


The  Application  and  Extraction  of  Heat. 

The  value  of  reducing  or  elevating  the  temperature  of  a  part  for  the 
purpose  of  securing  heinostasis,  is  too  well  known  to  require  comment  here. 
The  various  means  that  may  be  employed  are  shown  on  pages  222  to  227. 

Sponges. 

Notwithstanding  the  claims  of  various  authorities  and  manufacturers,  it 
still  remains  for  some  one  to  discover  a  substance  cheaper,  but  possessing 
all  the  good  qualities  of  marine  sponges.  The  softness,  elasticity,  strength 
of  fiber  and  great  absorbing  powers  of  natural  surgical  sponges,  seem  to 
defy  all  efforts  at  the  production  of  a  satisfactory  imitation.  Their  only 
disadvantages  are  their  cost  and  the  difficulties  encountered  in  sterilizing 
them. 

Surgical  sponges  possess  a  soft,  delicate  fiber  and  a  well-rounded  form, 
free  from  uneven  surfaces.  The  finer  grades  are  expensive,  and  except  in 


*"  ""         »T~  'a?**-'1'     r  »i»a5^."* 
v  '.•£  '     if.  •  •*      J  '    -X^?a«^ 

'     "^"   -•'     -f£.ff'f^^'  '    ^^  irf'.^ft?'- 

'••  '\  ^-.-^^  ."'^  X;  '**'•$£  '^  ^  .;"-^ 


Figure  686.      Flat  Abdominal  Sponge. 


Figure  685.    Jar  of  Aseptic  Sponges. 


Figure  687.    Surgeon's  Sponge. 


operations  where  the  cost  of  material  is  of  no  consequence,  it  is  necessary 
that  they  be  used  upon  different  cases  indefinitely.  Not  a  few  surgeons 
make  use  of  the  ordinary  Florida  Reef,  or  common  slate  sponge,  and  throw 
them  away  after  having  been  used  once  in  septic  cases,  as  they  prefer  a 
cheap  natural  sponge  to  any  imitation.  These  sponges  are  quite  low  in 
price,  but  are  objectionable  because  of  the  brittleness  of  their  fiber  and  con- 
sequent danger  of  pieces  being  detached,  which  might  escape  notice  and 
thus  be  enclosed  in  a  wound.  In  selecting  this  class  of  sponges,  only  the 
most  perfectly  formed  ones  should  be  employed. 

Surgeons'  sponges  may  be  procured  dry,  either  loose  or  on  strings,  or 
moist,  sterilized  in  jars  of  one  or  two  dozen  each.  Dealers  as  a  rule  offer 
surgeons'  sponges  for  sale  by  the  pound,  a  system  which  all  operators  should 


SPONGES.  309 

discourage.  Usually  such  sponges  will  be  found  heavily  "loaded"  with 
sand,  and  the  unsuspecting  buyer  will  frequently  be  told  that  in  their  nat- 
ural condition  "sponges  are  always  full  of  sand. "  Such,  however,  is  not 
the  case,  for  any  loose  grains  of  sand,  chalk  or  particles  of  stone  not 
enclosed  in  the  body  or  tissues  of  the  sponge  are  foreign  substances  placed 
there  for  the  purpose  of  profit.  Sponges  free  from  sand  are  seldom,  if  ever, 
sold  by  the  pound,  and  sponges  sold  by  the  pound  are  nearly  if  not  always 
"loaded."  This  condition  of  the  trade  is  largely  the  result  of  collusion 
between  importers  and  gatherers. 

As  natural  sponges  do  not  readily  absorb  fluids  unless  previously  moist- 
ened, it  is  necessary  that  they  be  stored  during  operations  in  a  vessel  con- 
taining some  antiseptic  solution.  As  the  number  of  sponge  applications 
required  during  an  operation  may  be  large,  they  must  be  used  over  and 
over  again.  It  is  necessary  that  their  absorbed  contents  should  be  extracted 
by  pressure,  or  "squeezing.  "  After  having  pressed  out  all  absorbed  fluids, 
they  should  be  quickly  washed  in  sterilized  water  and  then  in  an  antiseptic 
solution,  when  after  being  once  more  squeezed  dry,  they  are  again  ready 
for  use. 


Figure  688.    Artificial  Sponge.  Figure  689.    Absorbent  Abdominal  Pads. 

The  employment  of  the  same  sponges  upon  different  patients  unques- 
tionably increases  the  dangers  of  infection,  and  for  this  reason  their  use 
should  be  restricted  to  cases  where  a  substitute  can  not  be  successfully  util- 
ized. 

This  occurs  in  certain  cases,  such  as  operations  in  or  about  the  mouth, 
in  laparotomies,  and  occasionally  in  tamponning  wound  cavities.  What- 
ever system  of  disinfection  may  be  selected,  it  will  be  much  safer  to  supply 
so  many  sponges  that  a  fresh  lot  may  be  employed  for  each  day  of  the 
week ;  the  sponges  in  the  meantime  to  be  stored  in  antiseptic  solutions,  and 
each  container  to  bear  a  label  setting  forth  the  day  of  the  week  on  which 
the  contained  sponges  are  to  be  used.  This  will  insure  at  least  seven  days' 
immersion  in  a  proper  antiseptic  solution,  and  thus  greatly  lessen  danger 
of  infection. 

The  most  satisfactory  substitute  for  sea  sponges  is  absorbent  gauze,  and 
for  this  purpose  it  may  be  made  into  small  pads  or  gathered  into  small, 
somewhat  compact  circular  forms.  Gauze  is  preferable  for  this  purpose, 
because  it  possesses  fair  absorbing  qualities,  and  is  sufficiently  coherent  to 
prevent  the  separation  from  the  main  mass  of  small  filaments  and  other 
particles.  That  danger  from  this  source,  however,  may  not  occur,  it  is 
better  that  no  raw  edges  be  brought  into  contact  with  wound  tissues;  in 
other  words,  in  the  construction  of  the  pad  or  ball,  the  raw  edges  of  the 
covering  layer  should  be  "turned  in"  in  such  a  manner  that  the  raveling 


310 


MINOR    OPERATIVE    SURGERY. 


or  breaking  away  of  small  particles  will  not  occur.  Gauze  possesses  one 
advantage  over  natural  sponge  besides  that  of  cheapness  it  will  absorb 
when  dry. 

Many  surgeons  recommend  the  use  of  sponges  composed  of  a  roll  of 
absorbent  cotton,  enclosed  in  a  cover  of  antiseptic  gauze,  the  corners  of  the 
gauze  closely  gathered  together,  tied  with  a  sterilized  cord  or  thread,  and 
the  protruding  margins  closely  cut  away  with  scissors. 

Artificial  Sponges,  as  shown  by  figure  688,  are  more  largely  employed 
than  genuine  sea  sponges.  In  their  manufacture  great  care  should  be  taken 
to  turn  in  and  secure  by  stitching,  all  rough  or  frayed  edges,  that  the  borders 
may  be  smooth  and  even.  For  general  surgery  they  may  be  either  in 
sponge  or  pad  form,  and  may  be  composed  of  several  thicknesses  of  gauze, 
or  a  gauze  sack  filled  with  cotton,  moss,  wool  or  similar  substance.  The 
one  illustrated  is  the  more  common  form,  which  is  usually  made  of  gauze. 
They  can  be  purchased  in  various  sizes  or  made  by  the  nurse  or  other 
assistant. 

The  Absorbent  Abdominal  Pads,  imaged  in  figure  689,  may  be  made  as 
required  for  use  or  bought  from  dealers.  The  latter  usually  carry  them  in 
sizes  6  by  7  and  8  by  9  inches. 

Sponge  Holders. 

Sponge  Holders  are  rods  or  stems  to  which  sponges  may  be  attached  as 
a  cloth  is  fastened  to  a  mop  stick.  Forceps  with  catches  and  suitably 
shaped  jaws  are  also  employed.  The  former  may  be  in  the  shape  of  slen- 


Figure  690.    Sims'  Sponge  Holder. 

der  rods,  mounted  in  handles  and  terminating  in  jaws  or  clamps,  while  the 
latter  are  generally  of  scissors  handle  construction.  The  last-mentioned 
varieties  will  be  described  under  the  heading  of  laparotomy. 

Sims'  Sponge  Holder,  as  traced  in  figure  690,  is  one  of  the  oldest  and 
most  universal  patterns  in  use.  It  consists  of  a  brass  rod  and  handle,  the 
former  terminating  in  two  self-closing,  semi-circular  jaws,  the  opening  and 


Figure  091.    Hart's  Sponge  Holder. 

closing  of  which  are  controlled  by  a  sliding  ring  that  can  be  manipulated 
with  the  thumb  or  fingers.     Its  length  is  about  9  inches. 

Hart's  Sponge  Holder,  as  indicated  in  figure  691,  differs  from  Sims'  in 
substituting  for  the  small  sliding  ring  an  outer  tube,  long  enough  to  extend 
from  the  rear  portion  of  the  jaws  back  to  the  handle.  This  tube  at  its 


Figure  692.    Husson's  Aseptible  Sponge  Holder. 

proximal  end  terminates  in  a  collar  of  sufficient  diameter  to  admit  of 
manipulating  it  with  one  hand.  AVith  it  a  sponge  may  be  clamped  or 
detached  without  bringing  the  fingers  in  contact  with  the  sponge  or  the 
fluid  it  may  contain.  Its  length  is  9  inches. 


WOUND    IRRIGATION. 


311 


Husson's  Sponge  Holder,  as  evidenced  by  figure  692,  is  of  simple  con- 
struction. The  two  blades  are  manufactured  from  a  single  piece  of  metal, 
the  wire  loop,  constituting  the  handle,  being  extended  forward  to  form  the 
blades.  A  heavy  metal  collar  sliding  over  the  blades  compresses  the  self- 
opening  jaws.  Its  length  is  about  9  inches. 

Wound  Irrigation. 

As  irrigating  apparatus  for  use  in  the  operating-room  has  been  fully 


Figure  693.     Fountain  Syringe  Equipped  as  an 
Irrigator. 


Figure  694.    Combination   Water 

Bottle,  Fountain  Syringe  and 

Irrigator. 


described  on  page  121 ;  we  will,  in  this  chapter,   illustrate  only  some  of  the 
more  portable  designs. 


Figure 


Durand's  Aseptic  Syringe,  Douche  and  Irrigator. 


The  Fountain  Syringe,  illustrated  by  figure  693,  is  arranged  for  use  as 
an  irrigator.     It  may  be  of  from  three  to  five  quarts'  capacity,  and  either 


312 


MINOR    OPERATIVE    SURGERY. 


provided  with  an  Esmarch  cut-off,  as  shown  on  page  123,  or  a  plain  cut-off 
in  combination  with  a  set  of  glass  irrigating  tubes.  As  the  latter  can  be 
purchased  by  the  dozen  at  a  slight  cost,  the  surgeon  can  procure  and  keep 
them  on  hand,  and  thus  make  use  of  the  fountain  syringes  ordinarily  sold 
by  retailers. 

The  Combination  Fountain  Syringe  and  Water  Bottle,  shown  by  figure 
694,  is  compact ;  the  reservoir  may  be  detached  and  employed  as  a  water 
bottle.  It  does  equally  good  service  as  a  fountain  syringe  and  may  be  ob- 
tained with  the  same  tubes  and  cut-offs  as  the  pattern  previously  men- 
tioned. 

Durand's  Aseptic  Syringe,  displayed  in  figure  695,  may  be  used  in  con- 
nection with  almost  any  form  of  reservoir.  The  motive  power  is  gravity, 


Figure  696.    Lee's  Syphon  Syringe. 


acting  through  a  syphon,  while  the  starting  force  is  a  sliding  roller  clamp. 
When  the  apparatus  is  adjusted  for  use,  the  sliding  clamp  or  cut-off  should 
be  slipped  along  the  tube  until  only  a  few  inches  below  the  U-shaped  bend. 
As  soon  as  the  latter  is  in  position,  resting  on  the  edge  or  rim  of  the  reser- 
voir, the  current  may  be  started  by  pressing  the  halves  of  the  clamp  together 
and  drawing  it  downward  toward  the  nozzle,  thus  "stripping"  or  "milk- 
ing" the  tube.  By  tightly  pressing  the  halves  of  the  clamp  together,  a  lock 
is  formed  which  acts  as  a  cut-off,  thus  controlling  the  flow.  This  apparatus 
can  be  used  with  a  sterilized  pail,  pitcher,  or  other  receptacle.  If  carried 
in  a  bag,  the  space  employed  may  be  only  enough  for  the  rubber  tube,  cut- 
off and  irrigating  point. 

Lee's  Syphon  Syringe,  as  shown  in  figure  696,  is  of  the  ordinary  bulb 
injection  pattern,  but  is  provided  at  its  distal  end  with  a  U-shaped  clip, 
by  means  of  which  it  may  be  attached  to  the  rim  of  a  pitcher  or  pail,  and 
thus  held  in  position  during  use.  Its  proximal  end  is  provided  with  a  pipe 
and  a  cut-off  of  the  Esmarch  style.  The  bulb  may  be  utilized  to  start  a 


Figure  697.    Irrigating  Syringe. 


flow,  after  which,  if  the  reservoir  is  at  a  proper  height,  the  apparatus  will  pro- 
vide a  current  equal  to  a  fountain  syringe  or  other  irrigator. 

The   Plain   Hard  Rubber  Irrigating  Syringe,  pictured    in  figure  697,  is 
preferred  by  many   surgeons  to  any  other  form  of  portable   apparatus. 


DRAINS.  313 

It  can  be  procured  in  either  brass  or  hard  rubber,  usually  in  4,  6  and  8 
ounce  sizes,  each  supplied  with  suitable  tips. 

Drains. 

Drains  consist  of  means  for  the  escape  of  serum,  blood,  pus  or  other 
fluid  from  a  wound,  abscess  or  similar  tract.  Thorough  sterilization  of 
drains  should  precede  their  introduction.  Only  such  as  are  used  for  gen- 
eral purposes  are  mentioned  here,  as  special  patterns  will  be  described  in 
the  chapters  devoted  to  regional  surgery.  Drains  are  of  two  varieties: 
Absorbable  and  non-absorbable. 

Absorbable  Drains  possess  the  quality  of  being  taken  up  by  the  lym- 
phatic and  venous  systems,  so  that  having  fulfilled  their  use,  they  gradually 
disappear.  Owing  to  the  uncertain  results  attending  their  employment, 
they  are  now  seldom  employed.  They  are  of  two  varieties:  Capillary  and 
tubular. 

Absorbable  Capillary  Drains  are  never  indicated  in  the  presence  of  sup- 
puration. They  consist  of  a  number  of  strands  of  catgut,  kangaroo  tendon 
or  similar  substance,  bound  or  clasped  into  a  bunch  and  enclosed  in  a 
wound  by  being  placed  between  a  pair  of  sutures.  They  may  extend  to 
any  depth  desired,  care  being  exercised  to  see  that  they  are  evenly  and 
closely  laid  and  in  contact  with  each  other. 

Absorbable  Tubular  Drains  were  first  recommended  by  Neuber,  and 
consisted  of  tubes  prepared  from  the  cortical  portion  of  the  large  bones,  of 
cattle.  A  modification  of  these  was  suggested  by  Macewen,  who  constructed 
them  from  the  long  bones  of  fowls.  They  are  usually  absorbed  in  from 
eight  to  ten  days. 

The  Absorbable  Tubular  Drain,  as  delineated  in  figure  698,  is  of  decalci- 
fied bone.  To  further  assist  in  securing  drainage,  they  are  usually  made 


Figure  698.    Decalcified  Bone  Drainage  Tube. 

with  lateral  openings,  as  shown  in  the  illustration.  They  are  from  2  to  4 
inches  in  length,  and  of  varying  diameters,  from  7  to  10  millimeters. 

N on- Absorbable  Drains  are  of  three  varieties:  Capillary,  tubular,  and 
combined  capillary  and  tubular. 

Non- Absorbable  Capillary  Drains  are  usually  of  horsehair,  thread 
ligatures  or  gauze.  Either  of  the  former  should  be  inserted  in  the  same 
manner  as  the  absorbable  capillary  drains  before  mentioned.  Where  de- 
sired, a  portion  of  the  strands  may  be  removed  each  day  until  all  are  ex- 
tracted. Absorbent  gauze  may  be  utilized  for  this  purpose  by  cutting  it 
into  strips  of  the  desired  size,  one  of  which  may  be  removed  at  a  time  as 
desired. 

Tubular  Non- Absorbable  Drains  may  be  used  for  any  form  of  drainage, 
and  should  always  be  employed  if  pus  infection  be  present.  They  are 
manufactured  from  various  materials,  such  as  soft  rubber,  glass,  silver, 
aluminum,  nickel-plated  brass,  hard  rubber,  etc. ,  the  first  mentioned  being 
generally  preferred. 

Soft  Rubber  Drainage  Tubes. 

These  are  made  of  various  diameters  and  lengths,  as  desired,  from  pure 
gum  rubber  tubing.  In  the  employment  of  this  material,  the  surgeon  is 
able  to  cut  the  tubing  into  pieces  of  any  length,  and  where  desirable  the 


314 


MINOR    OPERATIVE    SURGERY. 


tube  may  be  partially  withdrawn  each  day,  cutting  away  the  protruding 
portion.  Many  are  perforated  by  lateral  openings,  usually  at  irregular 
intervals.  Care  should  be  taken  to  see  that  the  tube  is  not  partially  or 
wholly  occluded  by  being  flattened  or  kinked  from  pressure  of  surround- 
ing parts.  When  occlusion  or  obstruction  is  discovered,  it  will  be  better 
that  the  drain  be  promptly  removed  and  a  glass  or  metal  tube  substituted. 
Pure  gum  tubing,  suitable  for  drainage,  may  be  obtained  in  any  desired 
size.  If  specified  by  a  fractional  inch  scale,  the  surgeon  should  remember 
that  it  is  the  lumen  of  the  tube  and  not  its  external  diameter  which  deter- 
mines the  trade  size.  It  may  be  purchased  plain,  and  perforated  as  desired 
by  pinching  the  tube  flat  at  the  point  where  an  opening  is  desired  and 
snipping  out  a  piece  of  the  wall  with  a  pair  of  scissors;  or  it  may  be  pro- 
cured perforated,  either  by  the  yard  or  in  pieces  of  any  length.  Some 
dealers  have  adopted  a  scale  of  numbers  to  designate  the  various  sizes,  and 
to  avoid  confusion  we  have  induced  a  number  of  them  to  adopt  a  standard 


Figure  899.    India  Rubber  Drainage  Tube. 

scale,  a  rule  that  the  number  of  a  given  size  shall  be  the  same  as  the  num- 
ber of  sixteenths  of  an  inch  that  are  represented  by  the  diameter  of  the 
lumen  of  the  tube.  For  instance,  the  number  two  is  T2g-  of  an  inch  in 
diameter,  number  five,  T\  of  an  inch,  etc. 

Rubber  drainage  tubes  may  be  sterilized,  either  by  boiling  with  the 
surgical  instruments  or  steaming  with  the  dressings,  the  former  being 
preferred.  After  disinfection,  the  tubes  may  be  stored  in  a  3  per  cent,  solu- 
tion of  carbolic  acid,  care  being  taken  to  renew  the  solution  from  time  to 
time.  It  should  be  remembered  that  corrosive  sublimate  solutions  are  not 
suitable  for  this  purpose,  as  when  immersed  in  this  solution  for  any  length 
of  time,  a  chemical  action  takes  place  by  which  the  sublimate  is  precipitated. 


Figure 


laee  Tube  Bottle. 


The  best  receptacle  in  which  to  store  tubes  of  this  character  is  a  glass 
jar  of  sufficient  height  to  enable  the  operator  to  introduce  the  tubes,  each 
to  rest  on  its  end;  or,  if  this  is  not  practicable,  a  jar  of  sufficient  diameter 
to  enable  the  tubes  to  lie  flat  in  the  bottom.  They  should  rest  in  either 
case  straight,  or  nearly  so,  that  they  may  not  be  spoiled  by  being  bent  or 
curved. 

The  Antiseptic  Soft  Rubber  Drainage  Tube  Bottle,  depicted  in  figure 
700,  represents  a  metal-capped,  slender  glass  bottle  containing  half  a  dozen 
soft  rubber  drainage  tubes  of  assorted  sizes,  each  6  inches  in  length.  This 
is  a  convenient  package  for  the  emergency  case. 


DRAINS. 


315 


Drainage  Tube  Carriers. 

While  in  open  wounds  and  cavities  a  soft  rubber  drainage  tube  can  be 
placed  in  proper  position  either  with  the  fingers  or  dressing  forceps,  in  nar- 
row and  deep-seated  tracts,  some  form  of  probe  or  carrier  is  frequently 
necessary. 

Brims'  Drainage  Tube  Carrier,  the  form  of  which  is  made  clear  in 
figure  701',  is  applicable  in  tracts  having  two  or  more  connecting  openings. 
The  instrument  is  quite  flexible  and  may  be  curved  to  suit  the  peculiarities 
of  the  case.  The  tube  after  being  clamped  to  the  carrier  may  be  drawn 


TRUAX  GRF.ENEBCO. 

Figure  701.     Brims'  Flexible  Drainage  Tube  Carrier. 

into  one  and  out  at  a  second  opening,  after  which  it  may  be  released  and 
withdrawn  until  it  reaches  the  position  in  which  it  is  intended  to  remain. 
Hamilton's  Drainage  Tube  Carrier,  as  disclosed  in  figure  702,  consists 
of  a  flattened  metal  tube  containing  an  elastic  stylet,  that  may  be  moved 
backward  or  forward  by  means  of  a  button  or  thumb-piece.  This  stylet 
extends  slightly  beyond  the  distal  end  of  the  tube,  where  it  terminates  in 
an  acorn- shaped  bulb  provided  in  its  base  with  a  slot  of  peculiar  shape. 
The  drainage  tube  to  be  inserted  may  be  caught  and  held  between  this 


Figure  702.     Hamilton's  Drainage  Tube  Carrier. 

bulbous  tip  and  the  end  of  the  tube  by  simply  retracting  the  stylet  by  the 
thumb-piece.  When  passed  into  position  by  "the  carrier,  the  tube  may  be 
released  by  pushing  the  stylet  forward  far  enough  to  disengage  its  grip  on 
the  tube. 

The  slender  portion  of  the  bulb  may  be  unscrewed,  removed  and  replaced 
with  the  trocar  point  shown  in  the  illustration.  This  change  might  enable 
the  operator  to  pass  the  tube  through  certain  tissues  or  to  force  its  way 
along  a  sinuous  canal.  The  trocar  point  for  safety  is  carried  in  the  hollow 


Figure  703.    Hancock's  Drainage  Tube. 


handle,  the  opening  being  closed  with  a  screw  cap.       The  length  of  this 
instrument  is  10  inches. 

Hancock's  Drainage  Tube,  as  shown  in  figure  703,  consists  of  two  pieces 
of  soft  rubber  tubing,  usually  about  -/g-  of  an  inch  in  internal  diameter,  united 
along  their  lateral  borders  and  attached  at  their  proximal  ends  to  a  small 
oval  plate,  by  means  of  which  they  are  prevented  from  falling  into  the 
depths  of  the  wound.  In  external  measurement  they  are  usually  from  4  to 


316  MINOR  OPERATIVE  SURGERY. 

5  eighths  of  an  inch  broad  by  %  inch  thick.     The  usual  length  is  about 

6  inches,  but  they  may  be  shortened  as  required. 

Cabot's  Double  Drainage  Tube,  as  illustrated  in  figure  704,  is  an  impro- 
vised double  tube  that  may  be  utilized  to  good  advantage  where  special 
patterns  can  not  be  procured.  It  consists  of  a  piece  of  rubber  tubing  cut 
half  through  and  bent  full  upon  itself,  the  ends  passed  through  holes  in  a  soft 


Figure  704.    Cabot's  Double  Drainage  Tube.  Figure  705.    Hancock's  Drainage  Tube  Pin. 

rubber  plate,  and  held  in  position  with  safety  pins.  Such  a  tube  possesses 
all  the  advantages  of  the  more  expensive  patterns.  It  will  be  found  advan- 
tageous in  cases  where  it  is  desired  to  wash  out  a  cavity  containing  pus. 

Drainage   Tube  Pins. 

While  drainage  tubes  may  be  secured  from  slipping  into  the  cavity  by 
the  use  of  ordinary  safety  pins,  specially  designed  ones  are  frequently  pre- 
ferred. 

Hancock's  Drainage  Tube  Pin,  as  displayed  in  figure  705,  fonns  a  neat 
and  safe  fastener  for  soft  rubber  and  such  glass  tubes  as  are  provided  with 
suitable  perforations.  It  presents  a  large  bearing  surface  on  the  parts  at 
some  distance  from  the  tube,  thus  avoiding  any  risk  of  irritation  that  might 
be  assumed  by  the  use  of  common  safety  pins.  They  are  made  from  spring 
brass,  each  bent  from  a  single  piece.  Their  diameter  is  about  i  y2  inches. 

Drainage  Tube  Trocars. 

These  are  sometimes  employed  for  the  introduction  of  drainage  tubes, 
either  in  cases  following  tapping  or  where  it  is  desired  to  drain  a  dependent 
cavity  without  making  a  large  incision. 

Ingals'  Flat  Drainage  Tube  Trocar,  as  is  apparent  in  figure  706,  is  oval 
in  form  and  provided  with  a  close-fitting  canula.  The  instrument  should 


Figure  706.    Ingals'  Flat  Trocar  for  Introduction  of  Double  Drainage  Tube. 

be  of  sufficient  size  so  that  after  introduction  the  trocar  may  be  withdrawn 
and  two  pieces  of  drainage  tube  introduced  side  by  side  into  the  cavity. 
The  canula  may  be  permitted  to  remain,  or  if  there  be  no  danger  that  the 
surrounding  parts  will  press  upon  and  occlude  the  tubes,  it  may  be  with- 
drawn, leaving  the  latter  in  situ.  This  instrument  possesses  advantages 
over  an  operation  by  incision.  Its  only  disadvantage  is  the  small-sized 
tubes  that  must  of  necessity  be  employed,  owing  to  the  limited  size  of  the 
opening. 


DRAINS. 


317 


Metal  Drainage  Tubes. 

Various  materials  are  employed  for  the  manufacture  of  metal  drains. 
Silver,  aluminum  and  nickel-plated  brass  are  more  frequently  used. 
They  are,  however,  seldom  employed,  except  in  special  cases,  and  are, 
therefore,  usually  manufactured  to  order  and  require  no  further  mention 
here. 

Glass  Drainage  Tubes. 

This  material,  because  of  the  firmness  of  its  walls  and  the  readiness  with 
which  it  may  be  sterilized,  is  well  adapted  for  the  manufacture  of  drainage 
tubes  for  use  in  incised  vounds  where,  from  pressure  of  the  flaps,  there 
might  be  danger  of  occlusion  if  a  rubber  tube  were  employed. 


Q_ 


O 


o 


O 


Figure  707.    Gross'  Drainage  Tube,  Glass. 

Gross'  Drainage  Tube,  as  shown  in  figure  707,  represents  a  standard  form 
that  may  be  found  in  the  hands  of  dealers  generally.  The  openings  should 
be  of  good  size,  about  half  an  inch  apart.  Care  should  be  taken  when  pur- 
chasing to  see  that  the  ends  and  openings  are  smoothly  finished.  At  one 
end  of  each,  a  small  hole  passing  through  the  tube  from  side  to  side  should 
be  provided,  that  the  tube  may  be  secured  with  a  suitable  pin.  While  they 
may  be  manufactured  of  any  desired  length  or  diameter,  the  following  sizes 
have  been  adopted  as  standard : 

No.   i.   Length    63  mm.,  diam. 


2. 

3- 

4- 

5- 
6. 


63 
76 


114 


7  mm. 


4  holes. 
4 

5 
6 

7 

8 


126  10  9 

Combined  Capillary  and  Tubular  Drainage  may  be  secured  by  two  methods : 
First,  by  placing  the  capillary  drain  within  the  lumen  of  the  tube ;  second, 
by  including  the  capillary  drain  within  the  wound  but  external  to  the  tube. 
When  the  former  method  is  employed,  the  capillary  drain  may  consist  of 
gauze,  candle  wicking,  or  some  similar  substance  possessing  good  capillary 
powers.  It  is  particularly  applicable  in  deep-seated  drainage,  where  pus 
infection  is  present.  It  will  prevent  the  accumulation  of  pus  in  the  bottom 
of  the  tube,  and  thus,  in  a  measure,  guard  against  its  seeking  some  other  and 
more  harmful  outlet. 

Sutures. 

Sutures  are  employed  to  unite  the  opposing  margins  of  wounds  by  sew- 
ing or  stitching  them  together.  The  articles  required  are  sutures  and 
needles.  These  may  be  supplemented  by  needle  holders  and,  where  wire 
is  used,  by  twisters,  cutters,  clamps,  etc.  Sutures  may  be  classified  as 
absorbable  and  non-absorbable. 

Absorbable  Material  is  particularly  adapted  to  buried  sutures  and  liga- 
tures, because,  after  performing  its  function,  it  undergoes  liquefaction  and  is 
in  many  cases  replaced  by  living  tissue.  For  this  purpose  many  tendinous 
substances  have  been  employed,  including  the  tendons  from  the  ox.  moose, 
reindeer,  etc.,  and  the  tails  of  rabbits,  opossums,  kangaroos  and  whales. 
Those  usually  preferred  are  catgut,  kangaroo-tail  tendon  and  ox  tendon. 


318 


MINOR    OPERATIVE    SURGERY. 


Catgut. 

While  this  material,  when  first  placed  upon  the  market,  may  have  been 
manufactured  from  the  guts  of  the  domestic  cat,  the  catgut  now  employed 
in  surgery  is  obtained  from  the  intestines  of  sheep. 

The  best  qualities  of  catgut  are  prepared  from  sheep  from  the  moun- 
tainous districts  of  Italy.  In  its  preparation  the  small  intestines  are  detached 
from  the  mesentery  and  macerated  almost  to  the  point  of  decomposition, 
when  the  mucous  and  muscular  coats  are  removed  in  a  manner  similar  to  the 
process  used  in  the  manufacture  of  sausage  casings.  The  remaining  material, 
consisting  of  the  connective  tissue  layer,  is  split  into  strips  by  a  series  of 
sharp-bladed  knives.  These  strips  are  of  various  widths  according  to  the 
size  of  the  sutures  desired.  The  strands  are  formed  by  twisting  the  strips 
into  rope-like  forms  and  drawing  them  through  small  holes  in  a  steel  block, 
after  which  they  are  permitted  to  harden.  Rough  spots  and  uneven  sec- 
tions are  afterward  smoothed  with  pumice  stone. 

Owing  to  its  peculiar  construction,  catgut,  when  soaked  in  water  or 
aqueous  solutions,  becomes  soft  and  undergoes  a  certain  amount  of  expan- 
sion ;  this  is  due  to  the  fact  that  the  connective  tissue  cells  forming  the 
fibrous  coat  of  the  intestine  are  not  only  irregularly  disposed,  but  the  fibers 
cross  each  other  diagonally  much  in  the  same  manner  as  do  the  threads  on 


Figure 


)8.     Sho-wing  One  Suture  of  Dry  Sterilized 
Catgut  in  Air-Tight  Envelope. 


Figure  709.     Showing  10-foot  Coil  of 
Dry  Catgut. 


the  outer  covering  of  a  horsewhip  or  web  catheter.  The  tissues,  when 
examined  under  a  low  power  microscope,  are  found  to  resemble  the  threads 
in  a  strip  of  cloth  cut  diagonally  from  a  piece.  It  is  evident,  therefore,  that 
a  strip  of  catgut  must  depend  for  its  tensile  strength  on  some  substance 
that  will  prevent  its  fibers  from  moving  one  upon  the  other.  This  cement- 
ing substance  is  found  in  the  natural  secretions  contained  in  the  tissue,  and 
unless  macerated  or  softened  by  water  or  septic  exudates,  it  furnishes  a 
suture  that  will  withstand  a  heavy  strain. 

While  catgut  may  be  rendered  aseptic  without  destroying  its  tensile 
strength,  it  furnishes  a  fertile  culture  medium  for  almost  all  forms  of 
micro-organisms.  For  this  reason,  until  a  satisfactory  antiseptic  catgut 
can  be  prepared,  its  use  will  be  largely  confined  to  wounds  that  are  and 
can  be  maintained  aseptic.  When  in  a  dry  state,  it  possesses  too  much 
rigidity  for  suturing  purposes.  A  process  of  preparation  must,  therefore, 
be  selected  that  will  render  it  soft,  flexible  and  sterile,  one  that  will  impart 
suppleness  without  destroying  firmness.  Its  preparation  for  surgical  use  is 
fully  described  on  page  171,  under  the  head  of  "Sterilization,"  and  requires 
no  further  mention  here. 

In  cases  where  safety  demands  the  retention  of  the  suture  beyond  the 
usual  time,  or  where  over-rapid  absorption  would  endanger  the  success  of 
the  operation,  the  sutures,  first  antiseptically  prepared,  maybe  hardened  by 


SUTURES    AND    LIGATURES. 


319 


immersing  them  in  an  aqueous  solution  of  chromic  acid  (crystals)  i :  4000 
to  which  may  be  added  carbolic  acid  200  parts  for  48  hours,  after  which  they 
should  be  removed,  dried  and  kept  in  carbolized  oil.  Catgut  may  be  pur- 
chased in  about  ten  sizes,  and  in  various  forms,  among  which  are  the  fol- 
io win  of: 

In  coils  of  ten  feet  each. 

In  coils  hermetically  sealed,  20  inches  long. 

It  It  .  .  44  44  44 

40 

In  bottles  i  size  in  bottles  of  10  feet. 
"       "       3  sizes"         "       "   30     " 
"       6     "     "         "       "   90     " 
Figures  710  and  711   exhibit  portable  packages  for  thi  preservation  of 
catgut  and   other  suturing  material,  so  constructed  that  the  surgeon  can 
remove  any  required  amount  of  material  without  danger  of  contamination. 


Raw : — 

Dry  Sterilized 

(Boeckmann) 

Sterilized 
in  solution 


Figure  710.    Author's  Bottle  Figure  711.    Author's 
Containing  1  Size  B  o  1 1 1  e  Containing 

of  Catgut.  3  Sizes  of  Catgut. 


Figure  712. 


Ordinary  Bottle  of 
Catgut. 


Much  has  been  written  regarding  the  dangers  of  infection  incurred  when 
employing  the  ordinary  style  of  package,  as  illustrated  by  figure  712,  and 
as  usually  found  in  the  market.  Surgeons  have  insisted  that  the  corks  and 
stoppers  of  such  packages  were  liable  to  infection,  and  that  the  suture 
strands  while  being  drawn  through  the  openings  in  these  stoppers  were  at 
all  times  liable  to  contamination.  In  the  construction  of  the  package 
referred  to  it  was  sought  to  overcome  this  difficulty.  The  bottle  is  taller 
than  the  ordinary  pattern.  By  means  of  an  enlargement  near  the  top  of  the 
bottle  a  rubber  diaphragm  is  securely  held  in  place.  The  suture  material 
is  caused  to  pass  through  small  openings  in  this  diaphragm.  By  filling  the 
bottle  full  of  antiseptic  solution  and  cutting  off  the  ends  of  the  sutures 
below  the  water  level  but  above  the  diaphragm,  all  dangers  of  infection 
are  retrieved.  The  mouth  of  the  bottle  is  closed  with  a  rubber  stopper 
securely  held  in  place  by  a  metallic  screw  cap.  These  bottles  may  be  pro- 


320 


MINOR    OPERATIVE    SURGERY. 


cured  in  any  desired  size,  and  are  constructed  so  as  to  contain  spools  of  silk 
or  cylinders  of  catgut. 

Encapsulated  Catgut,  as  illustrated  by  figure  713,  usually  consists  of  a 
strand  of  catgut  about  10  feet  in  length,  wound  upon  a  glass  cylinder  and 
sterilized  according  to  the  formula  described  on  page  172.  After  steriliza- 
tion, the  cylinders  and  catgut  are  removed  from  the  boiling  liquid  with 


Figure  713.    Encapsulated  Catgut. 

sterile  forceps,  placed  in  sterile  test  tubes,  and  the  latter  partially  filled  with 
absolute  alcohol  and  enclosed  in  capsule  form.  When  aseptically  prepared, 
this  seems  to  furnish  an  ideal  method  for  the  preservation  and  transporta- 
tion of  sterile  gut. 

Kangaroo-Tail  Tendon. 

These  sutures  are  prepared  from  the  tail  tendons  of  the  Australian 
kangaroo,  a  species  known  by  the  natives  as  the  "Wallaby,  or  bush  kan- 
garoo," being  preferred.  In  this  substance  a  desirable  suture  material  is 
found,  the  fibers  of  which  are  disposed  in  lines  parallel  to  each  other,  thus 
furnishing  strands  of  unusual  strength  and  great  power  of  endurance.  The 
sutures  from  this  material  are  uniform  in  tensile  strength  and  furnish  a 
substance  for  knots  that  is  wholly  trustworthy.  They  possess  the  further 
advantage  when  compared  with  catgut  of  equal  size,  of  possessing  greater 


Figure  714.    Showing  Kangaroos  and  a  Single  Tendon. 


Figure  715.    Bottle  of  Kan- 
garoo Tendons. 


tensile  strength.  The  material  is  obtained  from  the  tail  of  recently  killed 
animals.  After  removal,  they  are  quickly  sun-dried,  after  which  they  may 
be  shipped  to  any  desired  point  without  danger  of  their  becoming  seriously 
infected.  They  possess  a  further  advantage  over  catgut  in  that  no  primary 
infection  is  likely  to  occur. 

In  their  preparation  the  tendons  are  softened  in  a  sublimate  solution 
of    i    to    1000,   after   which    they   are    easily    separable    into    sutures   of 


SUTURES    AND    LIGATURES. 


321 


uniform  size,  the  latter  depending  upon  the  size  of  the  animal  from 
which  the  tendon  is  secured.  After  separation  and  drying  they  are  ren- 
dered aseptic  by  soaking  in  a  solution  of  formaldehyde,  washed  in  sterile 
water  and  hardened  in  chromic  acid,  i  to  4000,  in  the  same  manner 
employed  in  the  preparation  of  catgut,  after  which  they  may  be  per- 
manently stored  in  a  carbolic  oil  solution,  i  to  10. 

When  wanted  for  use,  they  may  be  removed  from  the  container  and 
wrapped  in  a  sterilized  towel,  saturated  with  a  bichloride  solution,  i  to  1000. 
They  possess  an  advantage  over  catgut,  because,  when  placed  in  water,  they 
do  not  immediately  soften  or  swell,  and  their  tensile  strength  is  not 
impaired. 

The  strands  are  usually  from  12  to  20  inches  in  length.  They  are  par- 
ticularly adapted  for  buried  ligatures  and  sutures,  and  may  be  purchased  in 
the  market  in  bottles  containing  10  to  25  ligatures  each. 

Those  who  prefer  may  purchase  the  tendon  in  the  dry  state.  When 
thoroughly  dry,  it  can  be  re-sterilized  by  wrapping  it  in  dry  gauze  and 
placing  in  a  large  dry  test  tube  with  a  cotton  plug,  over  which  a  piece  of 
rubber  must  be  securely  tied.  Thus  prepared,  the  tube  can  be  placed  with 
the  instruments  in  the  sterilizer  without  injury  to  the  tendon.  A  very  little 


Figure  716.    Showing  Method  of  Stripping  Ox  Tendons. 


moisture,  however,  ruins  the  tendon.     Tendons  that  have  been  immersed 
in  oil  will  not  bear  sterilization  by  dry  heat. 

A  very  convenient  way  is  to  prepare  a  few  tendons  in  separate  test  tubes, 
a  number  of  tubes  at  a  time,  each  sufficient  for  an  ordinary  operation. 
Those  unopened  of  course  remain  sterile  indefinitely.  By  such  a  procedure 
the  operator  is  absolutely  sure  of  the  sterility  of  his  ligatures  and  sutures. 

Ox  Tendon. 

This  material  for  sutures  is  manufactured  from  the  tendon  of  the  leg  of 
the  ox ;  like  kangaroo-tail  tendon  it  possesses  the  qualities  necessary  in  an  ab- 
sorbable  suture.  As  the  substance  liquefies,  it  is  replaced  with  living  tissue. 

In  its  preparation  the  tendons  are  immersed  in  a  solution  of  chloride  of 
sodium  for  24  hours,  after  which  the  sheaths  are  detached  and  the  tendons 
partially  dried  and  split  into  sutures  of  the  required  size.  As  the  fibers 
lie  in  parallel  lines,  strands  of  any  degree  of  thickness  may  be  produced. 
Their  separation  is  assisted,  when  necessary,  by  beating  with  a  mallet,  by 
twisting  in  different  directions,  and  in  extreme  cases,  by  immersion  in 
water  to  which  has  been  added  a  little  surgical  soap.  They  are  rendered 
aseptic  by  immersion  in  bichloride  solution,  after  which  they  may  be  per- 
manently stored  in  any  prepared  liquid.  They  may  be  hardened  against 
absorption  by  immersion  in  a  solution  of  tannic  acid,  which  serves  to  toughen 

21 


322 


MINOR    OPERATIVE    SURGERY. 


or  tan  them.  They  may  be  procured  dry  in  any  quantity,  or  immersed  in 
alcohol,  25  to  100  sutures  in  a  bottle.  Their  usual  length  is  from  10  to  16 
inches. 

Non-Absorbable  Sutures.  These  are  usually  of  silk,  silkworm  gut,  horse 
hair  and  wire.  Other  substances  are  occasionally  employed,  such  as  cotton 
or  linen  thread,  but  in  such  limited  amounts  as  to  require  no  description 
here.  All  may  be  sterilized  by  boiling  in  water  or  by  steaming.  This  may 
be  accomplished  by  preparing  the  ligatures  separately  or  including  them 
with  the  instruments  or  dressings. 

Silk. 

Silk  thread  in  its  various  forms,  constitutes  one  of  the  most  valuable  and 
extensively  used  of  all  suture  materials.  Its  great  tensile  strength,  supple- 
ness of  fiber  and  non-irritant  qualities  place  it  in  the  front  rank  for  suturing 
and  ligating  purposes.  It  is  so  soft  and  pliable  that  it  may  be  readily  and 
closely  tied,  the  resultant  knots,  if  properly  formed,  being  safe  and  secure. 
Although  classed  as  non-absorbable,  when  used  as  a  buried  suture,  it 
becomes  encapsulated  in  the  cicatrix,  where,  although  the  process  is  slow,  it 
is  claimed  that  it  is  ultimately  absorbed.  If  properly  sterilized,  it  will  not 
tend  to  produce  suppuration,  nor  can  it  become  a  medium  for  the  propaga- 
tion of  bacteria. 

Silk  fiber  varies  according  to  the  country  in  which  it  is  produced.  The 
best  silk  for  surgical  purposes  is  manufactured  from  the  cocoons  developed 
in  the  "Tsatlee  Region"  in  China.  In  its  process  of  manufacture,  the  raw 


1 

r 

/            V. 

/        x. 

S    1 

s 

^ 

K 

\ 

1 

k 

^ 

*•*-            ' 

\         | 

1 
\ 

\ 

14  13          12  11  10  9  8  7  65  43  2 

Figure  717.    Showing  the  Approximate  Sizes  of  Both  Twisted  and  Braided  Silk. 

silk  in  skein  form  is  first  sorted  according  to  the  size  of  its  fiber,  and  is 
then  immersed  in  warm  water  for  several  hours  in  order  to  soften  the 
gums  and  secretions  with  which  the  fibers  are  frequently  matted  together. 
After  softening,  the  skeins  are  placed  upon  swifts  and  the  fiber  wound  on 
bobbins.  From  these  the  fibers  are  doubled  into  strands  by  spinning.  By 
the  aid  of  machinery  the  threads  are  stretched  smooth  and  rendered  firm 
and  dense,  those  which  are  used  in  surgery  requiring  extra  care. 

In  order  to  secure  a  uniform  color  and  finish,  it  is  necessary  that  the  silk 
be  passed  through  bleaching  and  dyeing  vats  during  the  manufacturing 
process.  This  portion  of  the  process  requires  great  care  in  order  that  the 
silk  may  be  not  injured  in  quality  of  fiber  and  that  poison  or  irritating 
chemicals  are  not  incorporated  with  it.  In  color,  it  is  usually  white  or 
light  pink,  although  for  the  use  of  some  operators  it  is  dyed  a  dead  black 
color. 

Many  advantages  are  claimed  for  iron-dyed  black  silk  because  of  the 
readiness  with  which  sutures  may  be  detected  even  when  deeply  imbedded 
in  soft  tissues.  While  the  demand  is  not  large,  manufacturers  have  placed 
it  upon  the  market  in  both  the  braided  and  twisted  form. 

A  special  quality  of  silk,  known  as  "cable  twist,"  was  first  introduced  to 
the  medical  profession  by  Tait.  It  differs  from  ordinary  silk  in  containing 


SUTURES    AND    LIGATURES. 


323 


the  gums  or  animal  matter  imparted  to  it  by  the  worm  in  the  spinning 
process.  In  the  manufacture  of  ordinary  silks,  these  substances  are  all 
extracted  by  a  boiling  and  washing  process. 

The  advantages  claimed  for  the  cable  twist  silk  are  that  it  is  of  firmer 
texture,  more  easily  manipulated  and  less  liable  to  slip  when  knotted. 
It  is  usually  found  in  the  market  in  the  form  of  skeins. 

Various  sizes  of  silk,  both  twisted  and  braided,  are  manufactured,  and  to 
assist  the  surgeon  in  selecting  the  sizes  wanted  when  ordering,  we  print 
the  diagram  shown  in  figure  717. 

The  tensile  strength  of  surgical  silk  has  heretofore  been  an  unknown 
quantity.  It  varies  with  the  quality  of  the  silk,  the  method  of  manufacture 
and  the  size  selected  for  a  given  number  by  the  dealer.  Believing  that  a 
standard  should  be  selected  that  would  at  least  represent  something,  the 
author  has  tested  nearly  all  the  surgical  silks  in  the  market,  both  twisted 
and  braided,  and  taking  an.  average  of  the  better  grades  as  a  standard, 
presents  the  following  as  fairly  representing  what  should  be  the  tensile 
strength  of  a  first-class  silk  ligature: 


Number. 

I 
2 

3 
4 

5 
6 

7 
8 

9 
10 


Twisted 

Silk. 


Braided 
Silk. 

2  lb. 


3 
4 
5 
7 
9 
ii 

13 
15 
18 


Number. 

II 
12 
13 
14 
15 

16 

17 
18 


Twisted 
Silk. 

8lbs. 


13 
17 
21 

25 
3° 

35 

45 

55 


Braided 
Silk. 


Ibs. 


24 
28 

33 

38 
43 

50 
57 
65 

75 


Silk  for  surgical  purposes  may  be  obtained  twisted,  braided  and  floss. 

Twisted  Silk  is  manufactured  by  combining  several  of  the  spun  strands 
into  a  single  thread,  the  size  of  which  is  regulated  by  the  number  of  fibers 
it  contains.  For  this  purpose  a  transferring  machine  is  employed.  To 
secure  a  firm  texture,  the  silk  is  rapidly  twisted  in  an  opposite  direction  to 
that  taken  in  the  spinning  process.  From  the  bobbins  thus  formed  it  is 
reeled  into  hanks  ready  for  the  dyeing  process. 

After  dyeing,  the  skeins  are  carefully  dried,  the  threads  polished  and 
finished,  and  wound  on  cards  or  spools,  or  cut  and  wound  into  small  skeins 
of  convenient  size  for  the  market.  But  little,  if  any,  twisted  silk  is  em- 
ployed in  surgery  excepting  the  following  qualities:  Ordinary  surgical 
silk,  cable  twisted  silk  and  saddler's  silk. 

Ordinary  Surgical  Silk  may  be  procured  dry  or  sterilized  in  the  follow- 
ing varieties  of  packages: 

fin  skeins  similar  to  saddler's  silk. 
•pv       I  White  or  iron-dyed,  one  size  on  a  card,  figure  724. 

' '      four  sizes  on  a  card,  figure  719. 
"     "        "      on  spools  of  ^  ounce  each,  figure  718. 
Of  r-r     j,    \  White  or  iron-dyed,  one  size  in  bottle,  figure  710. 

L(        "      "     "        "       three  sizes  in  bottle,  figure  711. 
Sterilized  silk   is  usually  rendered  aseptic  by  boiling  for  20  minutes, 
after  which  it  is  permanently  stored  in  carbolic  acid  solution,  i  :2o,  or  sub- 
limate alcohol,  i :  1000. 


324 


MINOR    OPERATIVE    SURGERY. 


Cable  Twist,  often  known  as  Tait's  silk,  is  usually  found  in  the  market  in 
skeins  or  hanks,  as  shown  in  figure  720.  The  lengths  contained  in  each 
hank  depend  on  the  size  of  the  threads. 

Saddler's  Silk  is  a  variety  of  sewing  silk  to  be  found  in  most  dry  goods 
stores.  It  is  usually  spun  from  short  fiber  silk.  It  is  imperfectly  manu- 
factured and  possesses  no  qualification  excepting  that  of  cheapness. 


Figure  718.    Showing  Spool  of  Silk. 


Figure  719.    Showing  Tablets  of  Assorted  Sizes 
of  Braided  and  Twisted  Silk. 


That  surgeons  may  form  some  idea  of  the  approximate  quantity  in  an 
ounce  of  the  various  sizes  of  twisted  silk,  we  insert  the  following  table : 

SIZES  AND  NUMBER  OF  YARDS  IN  EACH  OUNCE  OF  TWISTED  SILK: 


SIZE. 
I  

YARDS  TO 

WHITE. 
.2.26=; 

THE  OZ. 

IRON-DYED. 
I,  60Q 

2  

.1  86s. 

I,  1QQ 

•J     . 

.  .  I.  X  12 

1.  140 

A  .    . 

.  .1,108 

800 

^  .   . 

Q32 

600 

6  

76^ 

574 

7  •  • 

tfl 

A24 

8  

465 

37Q 

4.4.4. 

114- 

10.  . 

16$ 

274 

SIZE. 


12  

•  ~w 

.  .212 

11.  . 

I  7o 

,  .  I  16 

I<  .  . 

.IIC 

16  

.     QC. 

17  .. 

80 

18  

.     6"? 

10.  . 

.   c.o 

20.  . 

40 

YARDS  TO  THE  OZ. 

WHITE.  IRON-DYED. 

224 

174 


Braided  Silk  is  manufactured  by  braiding  together  several  strands  of 
twisted  silk.  The  plaiting  or  braiding  process  secures  a  firm,  even  cord  of 
great  tensile  strength,  although  its  special  advantage  is  the  ease  with  which 
it  may  be  manipulated. 

Figures  721  and  722  are  intended  to  illustrate  one  of  the  advantages 
possessed  by  braided  silk.  The  first  shows  the  manner  in  which  a  loop  of 


Figure  730.    Cable  Twist  Silk. 


common  silk  when  loosely  coiled  will  twist,  sometimes  more  tightly  than 
we  have  pictured,  causing  much  trouble  and  annoyance.  Braided  silk, 
however,  will  not  kink  or  curl  and  may  be  as  readily  manipulated  as  silver 
wire.  It  may  be  found  in  the  market  in  packages  similar  to  those  described 
in  connection  with  the  twisted  silk  before  mentioned.  The  aseptic  and 
iron-dyed  packages  are  prepared  in  the  same  manner  as  the  twisted. 


SUTURES    AND    LIGATURES. 


325 


Dry. 


f  White  in  skeins. 

or  iron-dyed,  one  size  on  card,  figure  724. 
]  four  sizes  on  card,  figure  719. 

"      on  spools  of  Y*  ounce,  figure  718. 

Q.     .,.      -,     (  White  or  iron-dyed,  one  size  in  bottle,  figure  710. 
o  Lcriiizcci    •(  ,  i  •          /* 

(  three  sizes,  figure  711. 


Figure  721.    Twisted  Silk. 


Figure  722.     Braided  Silk. 


Floss  Silk  is  a  straight  fiber  slightly  twisted.  It  is  usually  manufactured 
from  inferior  qualities  of  silk,  and  while  the  fibers  lie  parallel  to  each  other, 
they  lack  the  close  incorporation  that  imparts  to  the  regular  surgical  silk  its 
great  strength.  It  is  occasionally  employed  for  superficial  sutures  and  is 
much  used  in  the  manufacture  of  surgical  silks,  both  twisted  and  braided,  by 


IK     "YD  S 

Dental  noss. 
Warrants 


Figure  723.     Showing  Spool  of  Dental  Floss. 


Figure  724.     Showing  Card  of  Braided  or  Twisted 
Silk.    One  Size  on  Card. 


dealers  who  are  desirous  of  furnishing  supplies  which,  although  of  poor 
quality,  possess  all  the  external  characteristics  of  first-class  goods. 

Glass  Spools,  as  shown  by  figure  725,  may  be  obtained  in  any  desired 
torm  or  size,  from  the  long  spools  used  in  large  ligature  boxes  to  the  small 
bobbins  employed  where  ligatures  are  sterilized  or  stored  in  ignition  or  test 
tubes.  In  ordering,  the  purchaser  should  state  the  length  and  diameter 


326 


MINOR    OPERATIVE    SURGERY. 


wanted,  as  most  dealers  are  prepared  either  to  furnish  any  desired  size  from 
stock  or  to  manufacture  them  to  order. 

The  Small  Bobbins,  exhibited  by  figure  725,  are  particularly  adapted  for 
the  storing  of  sterilized  sutures  in  heavy  ignition  tubes,  as  illustrated  by 
figures  726  and  727.  In  operating,  the  sutures  are  each  wound  upon  a 
bobbin,  the  projecting  end  being  threaded  for  use. 


Figure  725.     Glass  Spools  and  Bobbir 


This  method  avoids  exposing  the  ligature  throughout  its  entire  length, 
and  thus  minimizes  the  danger  of  infection.  While  being  introduced,  the 
bobbin  may  be  held  in  the  hand  either  of  the  surgeon  or  assistant,  and  as 
the  suture  is  drawn  into  place  it  will  unwind  from  the  shaft.  This  plan  is  of 
advantage  when  several  arteries  are  to  be  tied  during  a  single  operation. 
Robb  advises  that  ligatures  be  prepared  by  winding  them  upon  bobbins  of 
this  class,  after  which  they  may  be  sterilized  by  placing  them  in  strong 
ignition  tubes,  as  shown  by  figure  727,  and  permanently  stored,  no  other 


Figure  726.    Ignition  Tube  with  Ligatures  Wound  on  Spools. 


Figure  727.    Ignition  Tube  with  Ligatures  Wound  on  Bobbins. 


stopper  being  employed  than  sterilized  non-absorbent  cotton.  As  absorb- 
ent cotton  absorbs  moisture  from  the  atmosphere,  it  is  unsuited  to  this 
purpose.  When  prepared  and  handled  under  aseptic  precautions,  this  is 
one  of  the  most  satisfactory  methods  yet  devised. 

The  Plates,  illustrated  in  figure  729,  are  intended  to  facilitate  the  cutting 
and  selecting  of  sutures.  The  full  length  strands  may  be  wound  upon  the 
plate,  after  which  they  should  be  bound  in  place  by  two  lateral  pieces  of 


SUTURES    AND    LIGATURES. 


327 


thread.  While  thus  bound,  the  strands  may  all  be  severed  at  one  end  with  a 
pair  of  scissors,  after  which  the  plate  may  be  placed  in  a  tall,  slender  jar  with 
the  cut  ends  down,  when  it  will  be  found  that  a  single  suture  may  easily  and 
quickly  be  drawn  from  the  plate  with  a  pair  of  dressing  forceps. 

These  plates  may  be  procured  in  lengths  from  six  to  ten-  inches,  thus 
insuring  sutures  of  from  12  to  20  inches.  If  desired,  they  may  be  wound 
and  cut  before  sterilization  and  permanently  stored  in  any  suitable  solution. 

The  Author's  Ligature  Bottle,  as  shown  in  figure  728,  consists  of  a  slen- 
der bottle  containing  a  frame  arranged  to  hold  three  reels,  upon  which  the 
stored  silk  or  catgut  may  be  wound.  The  frame  work  is  held  in  place  by 
a  soft  rubber  diaphragm,  placed  immediately  under  the  cork  where  it  is 
secured  by  lateral  pressure  in  a  projecting  space  formed  in  the  side  of  the 
bottle.  By  perforating  this  soft  rubber  disc  with  a  needle,  to  which  each 
of  the  ligatures  may  be  attached,  the  latter  may  be  drawn  through  the  rub- 


Figure  728.    Author's  Package  for 
Sterilized  Silk. 


Figure  729.    Glass  Plates  for  Silk  or 
Catgut  Ligatures. 


ber.  A  central  perforation  in  the  latter  admits  fluid  to  the  bottle.  The  dis- 
tance between  the  imder  side  of  the  rubber  stopper  and  the  disc  is  usually 
about  one-half  inch.  As  this  space  may  be  filled  with  solution  and  the 
ligature  ends  thus  covered,  no  infection  need  occur  if  the  bottle  and  cork 
are  sterile.  This  bottle  overcomes  a  serious  objection  heretofore  raised 
against  packages  of  this  kind. 

Schimmelbusch's  Ligature  Box,  as  defined  by  figure  730,  consists  of  a 
small  brass  box  with  hinged  top  and  front.  That  portion  of  the 
box  forming  the  front  is  double,  the  inside  plate  being  stationary.  The 
chamber  of  the  receptacle  is  provided  with  three  spools  of  good  size,  each 
mounted  on  a  fixed  axle.  Three  slots  are  provided  in  the  stationary  front 
wall  through  which  the  ends  of  the  silk  are  passed,  so  that  with  the  top 
closed  and  the  hinged  front  open,  silk  may  be  drawn  from  the  spools  with- 
out danger  of  infecting  the  contents  of  the  box.  The  construction  is  such 
that  after  the  spools  have  been  filled  with  silk,  the  whole  may  be  placed  in 


328 


MINOR    OPERATIVE    SURGERY. 


a  sterilizer  and  steamed  or  boiled,  after  which  the  box  may  be  dried,  and  the 
silk  thus  maintained  free  from  infection  for  an  indefinite  -period. 

Sylvester's  Ligature  Bottle,  as  portrayed  in  figure  731,  consists  of  three 
spools,  each  moving  independently  of  the  others,  all  mounted  in  a  solid  frame 
and  enclosed  in  a  suitable  bottle  with  a  water-tight  cap.  As  the  entire 
apparatus  is  constructed  of  hard  rubber  (with  the  exception  of  a  leather  or 
soft  rubber  washer),  there  is  nothing  that  will  corrode  or  be  easily  broken. 
To  prevent  the  entanglement  of  the  ligatures,  two  tubes  or  guides  are  pro- 
vided, so  constructed  as  to  extend  to  the  two  lower  spools,  through  which  the 
ligatures  pass  from  below  to  and  through  the  openings  provided  for  them  in 
the  upper  bar  of  the  frame.  As  the  outer  ends  of  the  ligatures  in  this  bot- 
tle are  immersed  in  the  fluid,  it  is  not  open  to  the  objection  frequently 
raised  against  those  bottles  in  which  the  ligatures  extend  through  the  cork 
and  outside  of  the  antiseptic  fluid. 

Schachner's  Ligature  Reel,  as  shown  in  figure  732,  consists  of  a  metal 
tup  with  a  water-tight  cover  to  which  is  attached,  depending  from  its  cen- 
ter, a  bar  upon  which  are  adjusted  nine  ligature  reels.  These  reels  are  so 


Figure  730.     Schimmelbusch's  Ligature  Box. 


Figure  731.    Sylvester's  Ligature  Bottle. 


arranged  that  each  easily  rotates  upon  a  fixed  axle  so  constructed  that  the 
sutures  may  be  wound  upon  them.  Upon  the  under  side,  attached  to  the 
cover,  a  thick,  soft  rubber  pad  is  firmly  secured.  This  pad  serves  as  a  pack- 
ing between  the  cover  and  the  cylinder,  thus  rendering  the  joint  water-tight. 
Nine  holes  are  provided  in  this  cover  through  which,  by  means  of  a  needle, 
the  ligatures  are  threaded  or  passed  through.  As  the  contact  with  this  pad 
securely  holds  the  ligatures  in  place,  they  may  be  unwound  without  opening 
the  box.  By  aid  of  this  appliance,  the  surgeon  may  safely  transport  in  al- 
most any  solution  (excepting  those  containing  sublimate)  nine  different 
varieties  or  sizes  of  sutures,  all  that  would  be  required  in  several  major  opera- 
tions. A  further  improvement,  suggested  by  Pratt,  is  to  elongate  the  cover 
into  a  cup  of  sufficient  depth  to  permit  the  introduction  beneath  it  of  a  round 
needle  box  ^  inch  deep. 

This  combination  enables  the  surgeon  to  transport  both  needles  and  liga- 
tures in  a  single  package. 

Silkworm  Gut. 

This  is  largely  employed  as  suturing  material,  and  for  this  purpose  pos- 
sesses some  advantages.     It  presents  a  smooth,  firm  surface,  causing  little 


SUTURES    AND     LIGATURES. 


329 


friction  when  drawn  through  a  needle  opening.  Being  of  solid  fiber,  with- 
out meshes,  its  strands  furnish  no  means  of  communication  for  the  passage 
of  disease  germs  to  deep-seated  tissues.  While  it  is  pliable,  forming  an 
elastic  loop,  it  possesses  a  sufficient  amount  of  firmness  and  rigidity  to  en- 
able the  operator  at  all  times  to  locate  the  whereabouts  of  the  different 
strands ;  and  as  it  exhibits  no  inclination  to  curl  or  twist,  the  strands  are  not 
likely  to  become  entangled  with  each  other.  In  this  respect  it  closely  resem- 


Figure  732.    Schachner's  Ligature  Reel. 

bles  silver  wire.  Unlike  the  latter,  however,  it  more  readily  conforms  to 
any  inequalities  or  curves,  and  for  this  reason  is  less  liable  to  produce  irrita- 
tion. Its  hard  and  unyielding  surface  renders  it  easily  sterilizable. 

It  is  claimed  that  sutures  of  this  material  may  be  left  in  position  for  a 
longer  time  than  any  other  non-absorbable  variety.  When  in  a  dry  state, 
this  substance  is  too  brittle  to  admit  of  close  tying.  It  should,  therefore, 
never  be  used  as  a  suture  or  ligature  until  it  has  first  been  soaked  in  some 


Figure  733.    Silkworm  Gut,  100 
Stn'ngs  in  Coil. 


Figure  734.    Extra  Quality 
Silkworm  Gut. 


Figure  735.     Package 

of  50  Horsehair 

Sutures. 


sterile  aqueous  solution  for  from  thirty  minutes  to  an  hour  preceding  its 
introduction.     It  may  be  threaded  as  easily  as  silver  wire. 

Ordinary  Silkworm  Gut,  as  exhibited  in  figure  733,  may  be  procured  in 
a  variety  of  qualities  and  lengths,  100  strands  in  a  bundle.  In  ligatures  it 
is  generally  about  thirteen  inches  in  length  and,  as  a  rule,  is  not  carefully, 
if  at  all,  selected  as  to  sizes. 


330 


MINOR    OPERATIVE    SURGERY. 


Selected  Surgical  Silkworm  Gut,  as  displayed  in  figure  734,  is  also  in 
bundles  of  100  each,  but  besides  being  smoother  and  generally  of  better 
grade,  it  is  carefully  assorted  as  to  size,  one  size  only  in  each  package. 
These  are  known  as  fine,  medium  and  strong.  They  may  be  obtained  in 
lengths  that  vary  from  thirteen  to  eighteen  inches,  the  13  to  15  inch  being 
usually  employed. 

Horse  Hair. 

Hair  taken  from  the  tails  of  horses  forms  an  excellent  material  for  cer- 
tain classes  of  sutures.  Since  its  first  introduction,  it  has  grown  in  favor, 
not  only  for  use  in  exposed  places  like  the  face,  where  scar  tissue  is  to  be 


Figure  736.     Melms'  Aseptic  Threaded  Ligatures. 

avoided,  but  where  the  wound  requires  light,  superficial  sutures  alternated 
with  heavier  ones.  To  prepare  it  for  surgical  use,  it  should  be  first  im- 
mersed in  a  4  per  cent,  boiling  soda  solution,  that  all  the  grease  and  other 
foreign  substances  may  be  removed.  After  being  carefully  brushed  and 
washed,  it  should  be  boiled  for  fifteen  minutes,  after  which  it  may  be  stored 
in  a  solution  of  carbolic  acid,  i  :2o,  or  in  sublimate  alcohol,  i  :iooo.  It  may 
be  procured  dry,  100  strands  in  a  bunch,  or  sterilized,  50  in  a  bottle — see 
figure  375,  prepared  according  to  the  method  above  described. 

Melms'  Aseptic  Threaded  Ligatures,  as  indicated  in  figure  736,  consist 
of  ordinary  surgical  needles,  threaded  with  sutures  of  various  sizes  and  kinds. 
They  are  intended  for  use  in  emergency  surgery,  where  the  surgeon  is  sud- 
denly called  upon  to  close  a  wound  with  sutures  and  where  convenience  or 
lack  of  time  will  not  permit  of  sterilization.  In  their  preparation  the 
needles  are  threaded,  the  sutures  coiled  in  a  loop,  and  the  whole  placed  in 
a  slender  glass  tube  three  or  four  inches  in  length,  closed  at  one  end 
and  of  the  proper  shape  to  fit  each  needle.  These  tubes  are  next  filled  with 
an  antiseptic  solution,  placed  in  a  sand  bath  and  boiled,  after  which  they 
are  hermetically  sealed.  When  required  for  use,  the  surgeon  has  only  to 
break  the  glass  tube,  and  the  suture  is  ready  for  use.  Sterile  water  to  wash 
a  superficial  wound  can  usually  be  obtained  from  any  kitchen.  This,  with 
the  aid  of  a  few  rubber  finger  cots,  which  may  be  sterilized  with  strong  car- 
bolic acid,  and  the  sutures  above  referred  to,  may  ofttimes  enable  the  sur- 
geon to  close  a  wound  antiseptically  without  the  loss  of  time  necessary  for 
sterilization. 

"Wire. 

Wire,  usually  of  silver,  is  often  employed  where  there  is  much  tension. 
It  is  particularly  adapted  for  holding  together  the  ends  of  bones  in  fractures, 
resections,  etc.  It  is  easily  and  certainly  sterilized,  and  for  this  reason  is 
frequently  employed  instead  of  silk  or  catgut,  because  there  need  be  no 
risk  of  infection  from  its  introduction. 

While  wire  other  than  silver  is  rarely  used  in  surgery,  an  occasional  oper- 
ator, probably  on  account  of  the  difference  in  price,  employs  that  drawn 


SUTURES    AND    LIGATURES. 


331 


from  the  baser  metals.  Of  these,  wire  from  iron  is  more  commonly  used ; 
it  should  be  untempered,  soft  and  malleable,  and  should  present  a  smooth, 
even  surface.  Copper  wire  is  occasionally  demanded,  and  may  be  either 
plain  or  silver-plated,  the  latter  being  usually  preferred.  Owing  to  its  cheap- 
ness and  the  fact  that  it  does  not  easily  corrode,  it  possesses  some  advan- 
tages. Wire  from  both  of  these  materials  may  be  obtained  of  any  size. 

Silver  wire  for  surgical  purposes  should  be  "pure  silver,"  soft  and  flexi- 
ble. It  can  be  found  in  the  market  in  almost  any  size,  from  Nos.  15  to  30, 
Brown  &  Sharp's  gauge.  As  the  fine  or  small  sizes  cost  no  more  per  ounce 
than  the  large  or  heavy,  it  should  always  be  purchased  on  the  basis  of 


Figure  737.    Silver  Wire. 


Figure  738.    Silver  Wire,  0  Spools  in  Box,  1  Yard 
on  Each  Spool. 


sib.  18  

.    7 

10  .  . 

20  

.  .  14 

21  

2O 

22  

.  27 

2?  .  . 

.  .  34 

24.  . 

..41 

weight.  Silver  wire,  as  shown  in  figure  737,  may  be  procured  in  coils  of 
one  pennyweight  each,  in  coils  of  ten  pennyweights  each,  and  in  boxes  con- 
taining six  assorted  spools,  as  previously  described.  The  author  recently 
weighed  and  measured  an  ounce  each  of  the  various  sizes  (Brown  &  Sharp's 
gauge)  of  silver  wire  and  found  each  ounce  to  contain  lengths  of  wire  ap- 
proximately as  follows: 

7  feet     No.   25 52  feet 

26 75 

27 100 

28 125 

29 150 

30 180 

Suturing. 

This  step  in  an  operation,  in  addition  to  sutures,  requires  means  for  their 
introduction.  While  soft,  pliable  material  like  silk  and  catgut  may  be  in- 
serted with  only  the  assistance  of  the  needle,  many  operators  employ  needle 
holders,  claiming  for  them  greater  accuracy  in  needle  manipulation.  Sil- 
ver wire,  owing  to  its  rigidity,  requires  special  appliances,  not  only  for  its 
insertion,  but  for  twisting,  clamping  or  otherwise  securing  the  suture  ends. 
The  patterns  described  under  this  heading  are  employed  for  general  pur- 
poses. Varieties  of  sutures  required  for  special  purposes  will  be  described 
under  the  various  headings. 

Needles. 

Needles  for  surgical  purposes  embrace  a  great  variety  of  shapes  and  sizes, 
varying  from  the  knife-like  incising  patterns  of  Hagedorn  to  the  round 
puncturing  design  of  Emmet.  As  a  rule,  the  readiness  with  which  needles 


332 


MINOR    OPERATIVE    SURGERY. 


penetrate  depends  on  the  form  of  the  point  and  cutting  edge.  Those  with 
sharp-cutting  edges,  although  more  easily  inserted,  make  larger  stitch  holes 
and  are  consequently  more  likely  to  be  followed  by  hemorrhage.  Round 
needles  that  puncture  only,  although  they  require  more  force  for  introduc- 
tion, are  considered  safer.  The  latter  are  exclusively  used  by  some  oper- 
ators for  buried  sutures.  As  a  mechanical  proposition,  it  is  evident  that  a 


Figure  739.    Straight  Surgeon's  Needles. 


Figure  740.     Half-Curved  Surgeon's  Needles. 


straight  needle  may  be  more  easily  introduced  than  a  curved  one,  although 
to  carry  the  point  of  such  a  needle  in  a  circle  curved  in  its  horizontal  plane 
requires  special  practice  and  experience.  Dudley  calls  special  attention  to 
the  advantages  of  straight  needles,  particularly  in  deep  suturing,  not  only'be- 
cause  the  position  of  the  point  may  be  always  known  by  its  depth  and  direc- 
tion, but  as  the  force  required  for  introduction  is  along  the  needle  line, 


Figure  743.    Plain  Fistula  Needles. 


Figure  741.    Full  Curved  Surgeon's  Needles. 


Figure  743.    Double  Curved  Surgeon's  Needles. 


there  is  less  danger  of  breakage  when  compared  with  curved  needles  when 
the  force  is  exerted  in  a  line  tangential  to  the  curve. 

The  general  forms  of  needles  are  straight,  full  curved,  half  curved  and 
double  curved.     Full-curved  needles  represent  the  arc  of  a  circle  that  may 


NEEDLES.  333 

be  of  any  length  or  size ;  half-curved  needles  are  made  with  straight  shanks 
and  curved  points,  while  double-curved  patterns  are  of  sigmoid  shape. 

While  needles  for  surgical  purposes  include  a  great  variety  of  shapes  and 
sizes,  the  operator  not  infrequently  enters  the  supply  store  of  the  seam- 
stress and  procures  for  some  special  purpose  (enterorrhaphy  for  instance) 
needles,  that  answer  his  uses  better  than  any  to  be  procured  from  the  instru- 
ment dealer. 

Needles  for  general  surgery  may  be  classified  as  ordinary  surgeon's, 
Hagedorn's  with  cutting  edges,  round,  and  Schnetter's,  to  which  may  be 
added  the  self-threading,  although  these  may  be  of  any  form. 

Ordinary  surgical  needles  are  of  five  varieties,  named  according  to  their 
shape:  straight,  as  in  figure  739;  half  curved,  as  in  figure  740;  full  curved, 
as  in  figures  741  and  742,  and  double  curved  as  in  figure  743.  They  have 
large  oval-shaped  eyes  that  they  may  admit  ligatures  of  good  size,  and  are 
all  widest  in  their  outer  third. 

Surgeon's  straight,  half-curved  and  full-curved  needles  may  be  pur- 
chased in  sizes  i  to  30,  as  shown  by  the  full-sized  illustrations  above  referred 
to.  Straight  needles  and  the  shanks  of  the  curved  varieties  are  oval  in  form, 
a  cross  section  of  which  is  shown  by  "A"  in  the  annexed  diagram.  The 
half  and  full-curved  varieties  are  flat  upon  the  outer  surface  of  the  curve, 
the  inner  side,  or  spine,  of  the  needle,  representing  the  two  short  sides  of 


A  B  C  D 

Figure  744.    Needles  Shown  in  Cross  Section. 

a  triangle,  as  is  shown  in  cross  section  by  "D."  This  form  gives  to  needles 
of  this  variety  a  semi-cutting  edge  which,  with  their  sharp  points,  permits 
easy  penetration  of  tissues. 

The  double-curved  needles  differ  from  half  and  full  curved  only  in  being 
bent  in  two  curves  instead  of  one.  They  are  sometimes  designated  as  "S, " 
or  sigmoid-shaped  needles.  Usually  surgeons  who  employ  them  do  not 
make  use  of  a  needle  holder.  Such  operators  select  this  form  of  needle  be- 
cause, as  they  claim,  the  upward  curve  nearest  to  the  eye  affords  a  better 
and  more  secure  grip  for  the  fingers.  Usually  they  can  be  obtained  only 
in  a  limited  number  of  sizes,  the  more  common  of  which  we  illustrate. 

Fistula  needles,  as  shown  by  figure  742,  differ  from  ordinary  full-curved 
needles  in  being  constructed  with  a  shorter  curve.  They  are  intended  for 
the  introduction  of  sutures  in  cavities  presenting  only  a  limited  operating 
space.  The  three  more  common  sizes  are  shown  in  the  figure  referred  to. 

Hagedorn's  Needles,  the  various  forms  of  which  are  outlined  in  figure 
745,  are  manufactured  from  flat  bars  of  fine  steel,  the  curved  varieties  being 
bent  on  the  edge  instead  of  on  the  flat,  as  in  the  ordinary  needles.  The 
perforating  awl-shaped  points  of  the  older  patterns  are  here  replaced  with 
a  trocar  shape,  sharpened  to  a  cutting  edge,  which  gives  to  these  needles  a 
greater  penetrating  quality,  so  that  but  little  force  is  required  in  their 
introduction. 

Figure  744  "C"  shows  a  cross  section  through  the  shaft  of  one  of  these 
needles.  The  difficulties  frequently  encountered  in  attempting  to  flatten 
the  firm  substance  of  a  ligature,  that  it  may  pass  through  the  narrow  oval 
eye  of  an  ordinary  needle,  are  overcome  in  the  Hagedorn  pattern  by  con- 
structing them  with  round  eyes,  that  that  may  be  easily  threaded. 

It  is  claimed  for  these  needles  that  the  openings  caused  by  their  use  do 
not  gape  or  spread  when  tightly  drawn  upon  by  the  sutures.  A  needle  of 


334 


MINOR    OPERATIVE    SURGERY. 


the  ordinary  curved  variety  leaves  an  opening,  the  long  diameter  of  which 
is  parallel  to  the  wound  margins.  The  tendency  of  a  deep  suture  in  such  a 
perforation,  if  drawn  tightly  enough  to  obtain  firm  approximation  of  the 
wound  walls,  would  be  to  open  and  spread  apart  the  sides  of  the  needle 
opening,  thus  providing  an  additional  point  for  infection.  It  should  be  re- 
membered, however,  that  a  slit  will  not  bear  as  much  strain  as  a  hole  made 
by  an  old  style  needle. 

The  use  of  a  needle  constructed  on  the  principle  of  Hagedorn's,  leaves 
a  slit-shaped  opening,  straight  and  at  right  angles  to  the  wound  margins, 
and  as  a  result  the  more  tightly  the  sutures  are  drawn,  the  more  closely  will 
the  sides  of  the  needle  opening  be  held  together.  On  account  of  the  ex- 
tent of  cutting  surface  common  to  this  needle,  operators  should  exercise 
great  care  that  blood-vessels,  nerves,  etc. ,  are  not  partially  or  completely 
severed  by  its  introduction.  Hagedorn's  needles  may  be  obtained  in  the 


Figure  745.    Hagedorn's  Needles. 

sizes  and  shapes  shown  by  figure  745  in  such  quantities  as  the  surgeon  may 
select,  or  they  can  be  purchased  assorted  in  cards  of  two  dozen  each,  as 
shown  in  the  illustration. 

Ferguson's  Needles  with  Cutting  Edge,  as  shown  in  figure  746,  while 
full  curved,  are  formed  upon  a  larger  circle  than  is  commonly  used  in  the 
manufacture  of  needles  The  shafts  are  in  form  like  a  flattened  oval,  curved 
on  the  flat  in  the  proximal  half,  and  on  the  edge  in  the  distal  portion 
The  points,  when  described  by  angles,  do  not  differ  from  those  of  Hage- 
dorn,  excepting  that  the  angle  of  the  cutting  edge  is  more  acute,  thus  fur- 
nishing a  much  more  slender  point  with  which  dense  tissues  may  be  more 
easily  penetrated.  The  eye  is  round,  that  it  may  be  easily  threaded.  It 
will  thus  be  seen  that  this  needle  possesses  all  the  advantages  of  the  Hage- 
dorn  pattern  and  does  not  require  a  special  holder  for  its  use.  Full  sizes 
are  shown  in  the  illustration. 

Ferguson's  Round  Needles,  as  delineated  in  figure  747,  are  full  curved, 
manufactured  from  round  wire,  the  proximal  portion  of  which  is  flattened 
that  they  may  be  firmly  held  in  the  jaws  of  a  needle  holder.  The  eyes 


NEEDLES. 


335 


are  round,  that  they  may  be  easily  threaded.  Each  represents  a  half  circle, 
the  diameters  of  the  circles  being  15,  20,  25,  32,  40  and  50  millimeters. 

Schnetter's  Needles,  as  shown  in  figure  748,  have  flat  Hagedorn-shaped 
shanks  with  triangular-shaped  points  curved  on  the  edge.  They  differ  from 
ordinary  surgical  needles  in  being  curved  sidewise  instead  of  flatwise. 
They  thus  possess  one  advantage  of  the  Hagedorn  pattern  in  that  the  long 
diameter  of  the  needle  opening  is  at  right  angles  to  the  wound  to  be  closed. 
The  point  is  long  and  slender,  thus  furnishing  with  the  cutting  edge  a  needle 
easily  introduced.  They  are  half  curved  and  may  be  obtained  in  any  desired 
size. 

Self-Threading  Needles,  as  set  forth  in  figure  749,  are  preferred  by  some 
operators  because  of  the  ease  with  which  a  ligature  may  be  passed  through 


Figure  746.    Ferguson's  Needles  with 
Cutting  Edge. 


Figure  747.    Ferguson's  Round  Needles. 


or  rather  into  the  eye.  They  differ  from  ordinary  needles  in  the  construc- 
tion of  the  eye,  which  is  slotted  or  open,  the  opening  connecting  with  a  V- 
shaped  recess  in  the  base  of  the  needle,  as  shown  in  the  illustration.  To 
thread  the  needle  it  is  necessary  only  to  lay  the  ligature  in  the  V-shaped 
opening  and  draw  tightly  upon  both  ends  in  the  direction  of  the  needle  point. 
This  will  cause  the  suture  to  spread  open  the  slot  and  admit  the  ligature 
into  the  eye.  Notwithstanding  the  advantages  claimed  by  the  manufacturer 
of  these  needles,  they  have  only  a  limited  sale.  They  can  be  procured  in 
the  same  sizes  and  shapes  as  ordinary  surgical  needles. 

Glovers'  Needles  are  employed  by  many  surgeons  in  certain  operations. 


Figure  748.     Schnetter's  Needles. 


Figure  749.     Surgeon's  Needles— Self- 
Threading,  Spring  Eye. 


They  are  straight  with  round  shafts  and  long  triangular  points.  They  may 
be  purchased  not  only  from  the  general  supply  houses,  but  from  harness 
makers  and  dry-goods  houses. 

Needle  Boxes  and  Bottles. 

Surgical  needles  are  seldom,  if  ever,  nickel-plated,  and  therefore  quickly 
rust  and  become  unfit  for  use  if  handled  with  moist  fingers  or  permitted  in 
any  way  to  become  damp.  For  this  reason  many  surgeons  employ  a  for- 
ceps for  handling  needles,  and  when  transporting  or  storing  them,  keep 
them  in  some  form  of  box  or  bottle.  If  placed  in  a  proper  container,  to 


336 


MINOR    OPERATIVE     SURGERY. 


which  has  been  added  a  small  quantity  of  oil  or  petrolatum,  they  may  be 
kept  smooth  and  bright  indefinitely. 

The  Aseptible  Needle  Case,  as  detailed  in  figure  750,  illustrates  a  metal- 
lic case  in  which  surgical  needles  may  be  both  sterilized  and  transported. 
It  consists  of  a  box  and  cover  of  shallow  construction  containing  a  removable 
plate  to  which  a  spiral  spring  is  attached  in  such  a  manner  that  the  coils 
forming  the  spiral  may  be  utilized  for  holding  the  needles.  The  latter  may 
be  placed  in  the  grasp  of  the  spring  at  any  desired  point. 

The  entire  case  with  the  needles,  or  the  plate  and  needles  alone,  may  be 


TRUAX.GREENE&CO 


Figure  750.     Aseptible  Needle  Case. 

immersed  in  a  boiling  solution  for  sterilization.  This  arrangement  not  only 
supplies  these  advantages,  but  the  surgeon  or  assistant  can  quickly  remove 
any  needle  contained  in  the  box. 

The  Crescent  Needle  Bottle,  described  in  figure  751,  is  best  explained 
by  the  illustration.  The  small  cap  covering  the  opening  or  mouth  is  of 
metal,  fitting  closely  to  the  bottle  neck.  The  peculiar  shape  renders  these 


Figure  751.    Crescent  Needle  Bottle. 


Figure  752.     Berlin  Needle  Bottles. 


bottles  suitable  for  use  as  containers  for  needles  of  assorted  shapes  or  sizes. 
They  are  manufactured  in  three  sizes. 

The  Berlin  Needle  Bottles,  as  they  appear  in  figure  752,  are  manufac- 
tured in  three  shapes  and  in  various  sizes  of  each  shape.  Those  that  are 
slightly  curved  will  admit  straight  needles,  while  the  more  sharply  curved 
varieties  may  be  procured  to  fit  needles  of  any  desired  form.  Each  bottle 
is  constructed  with  a  ring  or  collar  at  its  neck  or  opening  to  which  a  cap  is 
attached  by  a  screw. 


NEEDLE    HOLDERS.  337 

Needle  Holders. 

These  are  almost  a  necessity  in  closing  wounds,  even  those  of  a  super- 
ficial nature,  while  in  inserting  deep-seated  sutures,  they  are  practically  in- 
dispensable. As  there  is  a  great  diversity  of  opinion  among  operators  as  to 
the  proper  form  and  size  of  needle  holders,  they  are  made  in  a  great  variety 
of  patterns.  They  differ  in  shapes  of  handles  and  forms  of  jaws  and  are, 
of  necessity,  modified  to  meet  the  requirements  of  special  needles  and  the 
character  of  the  work  to  be  performed. 

Many  operators  of  note  employ  needle  holders  without  catches,  claiming 
they  can  more  quickly  grasp  or  release  a  needle  when  not  hampered 
with  the  mechanism  of  a  lock.  Others  argue  that  a  catch  is  a  necessity,  be- 
cause there  is  less  danger  of  accidentally  dropping  or  displacing  the  needle, 
and,  as  is  often  the  case,  if  the  operator  is  compelled  for  a  moment  to 
release  his  grip  or  lay  aside  the  holder,  the  needle  is  not  separated  therefrom. 

It  is  well  to  remember  that  it  is  better  not  to  grasp  a  needle  at  its  eye 
because  of  the  danger  of  crushing  at  this  point. 

In  the  selection  of  a  needle  holder  for  operations,  where  only  local  anes- 
thesia is  employed,  the  surgeon  should  select  one  that  will  both  grasp  and 
release  the  needle  noiselessly.  The  clicking  sound  is  objectionable  to  many 


ABC 

Figure  753.    Sectional  Views  for  Illustrating  Comparative  Shapes  of  Jaws  of  Needle  Holders. 

nervous  patients,  and  applies  particularly  to  operations  upon  the  eye.  In 
many  cases  the  clicking  noise  causes  considerable  shock  to  patients,  all  of 
which  may  be  avoided  by  the  selection  of  a  proper  holder. 

While  the  ordinary  needle  holders  in  the  market  answer  every  purpose 
•with  straight  or  half-curved  needles,  it  is  a  matter  of  common  complaint 
that  they  are  defective  when  used  to  facilitate  the  introduction  of  full- 
curved  needles,  or  for  grasping  a  partially  curved  needle  at  any  point  along  its 
curved  portion.  This  defect  in  construction  is  due  to  the  fact  that  one  or 
both  of  the  jaws  or  grasping  surfaces  of  most,  if  not  all,  of  the  needle  hold- 
ers in  common  use  are  either  flat  or  convex,  so  that  the  force  necessarily 
employed  to  firmly  hold  such  needles  tends  to  straighten  them,  and  as  nee- 
dles are  highly  tempered,  they  frequently  break  under  the  pressure  exerted 
by  the  handles.  The  author  selected  twenty-five  full-curved  needles  of 
good  quality  and  of  various  sizes,  and  subjected  each  to  the  pressure  of  an 
ordinary  Russian  needle  holder,  grasping  each  one  at  two  different  points, 
one  near  the  eye  and  the  other  near  the  point.  The  result  was  that  seven 
needles  were  broken,  although  no  more  force  was  employed  than  was 
thoiight  necessary  to  hold  the  needles  firmly  enough  for  ordinary  suturing. 
Believing  this  defect  might  be  overcome,  a  series  of  experiments  was 
instituted,  resulting  in  the  construction  of  a  needle  holder  that,  under  the 
same  conditions  and  circumstances  as  above  mentioned,  failed  to  break  even 
one  of  a  fresh  lot  of  twenty-five  assorted,  full-curved  needles. 

Needle  holders  with  flat,  convex  and  concave  jaws  of  different  patterns 

22 


338  MINOR    OPERATIVE    SURGERY. 

and  in  various  combinations  were  manufactured,  but  not  until  an  instru- 
ment with  two  concave  jaws  facing  each  other,  and  with  thin  rims  or  nar- 
row grasping  surfaces  was  devised,  was  the  objection  overcome.  A  needle 
grasped  between  two  convex  surfaces  would  admit  of  any  amount  of  pres- 
sure with  safety,  but  there  was  nothing  in  the  shape  of  the  jaw  to  prevent 
its  easily  turning  to  one  side.  Both  of  these  objections  were  successfully 
met  in  the  model  described  by  figure  756. 

Figure  753,  "A"  exhibits  the  relations  of  an  ordinary  needle  holder  and 
curved  needle;  "B"  shows  the  action  of  the  holder  and  why  curved  needles 
are  frequently  broken ;  "C"  shows  the  improved  design.  The  needle  being 
in  contact  with  the  holder  at  two  points,  is  firmly  held  from  being  turned 
to  either  side,  while  the  cavity  of  the  lower  jaw  accommodates  the  curve 
of  the  needle,  so  there  is  no  danger  of  breakage.  As  both  jaws  are  alike, 
the  holder  may  be  used  right  or  left.  As  many  operators  occasionally  use 
a  needle  that  penetrates  in  a  line  with  the  axis  of  the  handle  or  on  a  line 
parallel  with  it,  the  jaws  were  curved  on  the  flat,  thus  allowing  the  use  of 
either  a  straight  or  a  full-curved  needle  pointing  in  the  same  direction  as 
the  holder.  This  improved  form  of  a  needle-holding  jaw  may  be  applied 
to  almost  any  of  the  forms  of  handles  in  common  use. 


Figure  754.    Finger  Needle  Holder. 


The  Finger  Needle  Holder,  the  form  of  which  is  explained  by  figure 
754,  is  a  short  instrument,  with  the  author's  improved  form  of  jaws. 
This  instrument  was  so  named  because  the  needle,  when  held  by  the 
instrument,  is  in  such  close  proximity  to  the  fingers,  that  the  sense  of 
touch  is  quickened  and  much  lost  motion  obviated.  It  can  be  operated 
with  more  precision  than  a  needle  held  by  the  unaided  fingers,  while  its 
grip  is  much  stronger  and  more  effective.  The  needle  is  here  shown  grasped 
in  the  center,  the  better  to  show  how  easily,  by  means  of  the  curved  jaw 
"straight  ahead"  sutures  may  be  inserted.  In  use  the  needle  would  be 
clasped  near  the  eye. 

A  further  improvement  has  been  suggested  in  the  jaw  of  this  forceps, 
which  consists  in  cutting  perpendicular  grooves  of  the  width  of  a 
medium-sized  Hagedorn  needle,  in  order  that  the  holder  may  be  used 
for  needles  of  this  pattern.  Its  length  is  2^  inches. 

The  Pocket  Needle  Case,  traced  in  figure  755,  is  adapted  for  emergency 
work.  It  contains  a  finger  needle  holder,  as  sketched  in  figure  754,  two  dozen 
assorted  needles  and  a  card  of  braided  silk  of  assorted  sizes.  The  case  is 
only  31^  inches  long,  2  inches  wide  and  %  inch  thick. 


NEEDLE    HOLDERS. 


339 


The  Automatic  Needle  Holder,  with  author's  style  of  jaw,  as  drawn  in 
figure  756,  exhibits  the  form  of  jaw  previously  described,  in  combination 
with  a  handle  that  operates  with  an  automatic  self-clasping  and  unclasping 
catch.  In  the  construction  of  this  forceps  the  handle  ends  are  curved  as 
shown  in  the  illustration,  each  terminating  in  a  catch  so  adjusted  that  the 
two  form  a  lock  when  the  handles  are  pressed  together. 


Figure  755.    Pocket  Needle  Case  Containing  Finger   Needle  Holder,  Two  Dozen   Ordinary  or   Hage- 
dorn's  Needles  and  Cards  of  Assorted  Sizes  of  Braided  Silk. 

While  this  lock  is  sufficient  to  hold  a  needle  securely  in  almost  any  posi- 
tion, the  latter  may  be  instantly  released  by  squeezing  the  handles  together. 
What  in  the  illustration  appears  to  be  a  second  ratchet  on  the  lower  handle 
on  its  rear  surface  is  an  incline  by  which  the  catch  on  the  upper  handle  is 
forced  past  this  point.  When  the  pressure  of  the  hand  is  relaxed,  this  up- 
per catch  is  guided  behind  the  lower  one  as  it  moves  outward  under  the 
force  of  the  spring,  thus  releasing  the  handles  each  from  the  grasp  of  the 
other. 

This  forceps,  when  properly  manufactured,  is  a  very  desirable  pattern, 


Figure  756.    Automatic  Needle  Holder  with  Author's  Form  of  Jaw. 

for  by  simple  closure  with  a  firm  grasp  it  locks,  and  under  a  tight  grip  it 
unlocks.  It  therefore  apparently  combines  the  advantages  of  needle  hold- 
ers with  and  without  locks.  When  locked,  the  breadth  of  the  handles  is 
sufficient  to  give  the  surgeon  a  firm,  full-handed  grasp,  something  not 
obtainable  in  the  narrow  patterns.  This  grip  is  made  more  secure  by  the 
deep  serrations  cut  upon  the  outside  of  both  handles.  The  length  of  the 


340 


MINOR    OPERATIVE    SURGERY. 


regular  pattern  is  7  inches,  a  special  length  of  9  inches  being  manufactured 
for  gynecological  use. 

Emmet's  Needle  Holder,  as  set  forth  in  figure  757,  is  constructed  with- 
out a  catch.  Its  handles  are  of  such  weight  as  to  give  them  a  good  spring 
when  firmly  held.  One  jaw  is  faced  with  soft  copper,  that  the  edges  and 
contact  surface  of  the  hard  steel  needle  may  slightly  embed  themselves  in 
the  copper  when  tightly  grasped  by  the  forceps.  Its  length  is  7  inches. 


Figure  757.    Emmet's  Needle  Holder. 

The  Improved  Russian  Needle  Holder,  as  it  appears  in  figure  758,  is  one 
of  the  most  widely-known  patterns.  As  originally  constructed,  it  was 
necessary  to  lock  it  by  a  special  movement  of  the  thumb  by  which  the  catch 
was  drawn  downward  and  the  handles  locked.  As  here  shown,  the  locking 
device  works  automatically,  requiring  no  attention  on  the  part  of  the  sur- 
geon excepting  to  release  its  grasp,  which  is  done  by  pushing  the  thumb- 
piece  forward.  The  length  of  the  instrument  is  7  inches  and  one  of  the 
jaws  is  copper  faced.  It  may  also  be  procured  with  jaws  like  those  shown 
in  figure  756. 


Figure  758.    Improved  Russian  Needle  Holder. 

Ferguson's  Needle  Holder,  as  illustrated  in  figure  759,  exhibits  a  needle 
holder  of  great  strength  and  firmness.  It  is  manufactured  with  a  shears 
handle  and  presents  a  combination  that  will  not  only  firmly  hold  the  needle, 
but  will  give  to  the  surgeon  perfect  control.  This  holder  is  principally 


Figure  759.    Ferguson's  Needle  Holder. 

adapted  for  the  management  of  large  needles,  particularly  those  employed 
in  closing  abdominal  incisions.      Its  length  is  6  inches. 

Harris'  Needle  Holder,  as  set  forth  in  figure  760,  presents  two  features 
that  are  new  in  the  mechanical  construction  of  surgical  instruments.     The 


NEEDLE    HOLDERS. 


341 


jaws  are  so  shaped  that  with  them  a  curved  needle  may  be  grasped  at  any 
point  without  danger  of  breaking.  The  under  blade  is  manufactured  with  a 
longitudinal  trough  or  depression  extending  throughout  its  grasping  surface. 
The  lateral  margins  are  traversely  serrated,  the  inner  borders  being 
slightly  lower  than  the  outer.  The  upper  or  riding  jaw  is  slotted  from  the 
tip  backward,  the  inner  margins  which  form  the  grasping  surface  on  both 


clfe 

Figure  760.    Harris'  Needle  Holder. 

sides  being  beveled  from  within  outward,  so  that  a  needle  of  short  curve 
may  be  grasped  with  only  two  narrow  points  of  contact.  The  jaws  are 
therefore  fitted  for  holding  smooth  round-curved  needles  without  regard  to 
size,  there  being  no  danger  of  the  needle  turning  on  its  long  axis.  The 
proximal  end  is  supplied  with  a  series  of  ratchet  catches  by  which  different 
degrees  of  pressure  may  be  obtained. 

A  second  new  feature,  the  mechanism  of  which  was  first  called  to  our 
notice  in  this  instrument,  is  a  form  of  release  catch  by  which,  with  slight 
finger  pressure,  the  retaining  catch  may  be  easily  and  certainly  released. 
This  movement  is  secured  by  a  catch  in  trigger  form,  the  exact  shape  of 


Figure  761.     Halsted's  Needle  Holder 

which  is  shown  by  the  illustration.  A  delicate  spring  holds  the  catch  in  such 
a  position  that  it  forms  a  contact  with  the  ratchet  on  the  opposite  handle 
when  the  two  are  closed. 

Halsted's  Needle  Holder,  as  shown  by  figure  761,  is  so  constructed  that 
the  jaw  or  grasping  surface  is  at  a  right-angle  with  the  handle  of  the  instru- 
ment. The  jaws  are  short,  strongly  built  and  well  adapted  for  grasping 
almost  any  form  of  round,  square  or  Hagedorn-shaped  needle.  The  blades 
are  separable  by  an  ordinary  pin  lock,  an  ear  or  wing  projecting  over  the 
removable  blade  preventing  accidental  misplacement  when  in  use.  A 
double  spring,  half  of  which  is  attached  to  each  handle,  serves  to  keep  the 
jaws  apart.  The  instrument  is  usually  about  8  inches  in  length. 

Bvford's  Needle  Holder,  as  outlined  in  figure  762,  is  made  without  lock 
and  is  constructed  with  curved  flanges  that  project  backward  from  the  rings 
of  the  handles.  These  flanges,  passing  just  inside  and  firmly  against  the 
thumb  and  middle  finger,  serve  as  does  the  stock  of  a  gun,  to  keep  the  pro- 
jecting part  steady,  and  to  assist  in  accurately  manipulating  the  same. 


342 


MINOR    OPERATIVE    SURGERY. 


The  jaws  are  bulbous  shaped  and  provided  with  grooves,  so  that  a  needle 
may  be  held  in  almost  any  position. 

As  this  instrument  possesses  a  long  handle,  it  is  well  adapted  for  suturing 
in  deep  cavities,  the  peculiar  shape  of  the  handles  permitting  the  use  of 
the  entire  hand  in  cases  where  much  force  is  necessary.  As  the  finger  and 


Figure  762.    Byford's  Needle  Holder. 


thumb,  by  virtue  of  their  contact  with  the  handles,  are  enabled  to  accur- 
ately guide  the  instrument,  it  is  well  adapted  for  delicate  as  well  as  heavy 
work.  It  is  simple  in  design,  being  composed  of  only  two  pieces.  Its 
extreme  length  is  9  inches. 


Figure  763.    Hanchett's  Needle  Holder. 


Hanchett's  Needle  Holder,  as  detailed  in  figure  763,  consists  of  a  solid 
steel  handle  and  shank,  terminating  at  its  extremity  in  a  slight  projection 
or  elevation,  curved  at  a  right  angle  to  the  handle.  A  suitable  cam,  in 
handle  form,  is  pivoted  to  the  shank  in  such  a  manner  as  to  wedge  and 
tightly  hold  a  needle  or  similar  article  when  placed  between  it  and  the  pro- 


Figure  764.    Reiner's  Needle  Holder. 

jection  above  referred  to.  To  firmly  grasp  a  needle,  it  is  necessary  only  to 
turn  the  cam  at  right  angles  to  the  handle,  place  the  needle  in  position, 
when  it  will  be  found  by  turning  the  cam  to  the  left  that  any  degree  of  press- 
ure desired  may  be  obtained. 

Its  advantages  are  simplicity  of  construction,  absence  of  springs  and 
catches,  ease  of  manipulation,  and  the  firmness  with  which  a  needle  may 
be  held.  So  great  is  its  strength  in  this  direction  that  heavy  needles  may 
be  broken  more  easily  than  they  can  be  forcibly  dislodged.  The  instru- 
ment is  easily  cleaned,  and  will  hold  any  form  of  needle,  plain  or  Hagedorn. 

Reiner's  Needle  Holder,  as  explained  by  figure  764,  is  a  combination  of 
the  broad,  full-handed  pattern  of  handles  and  the  self-locking  device  of 
the  improved  Russian.  It  is  constructed  with  one  jaw  faced  with  copper, 


NEEDLE    HOLDERS. 


343 


as   shown    in  figure    757.     It   is  usually   made   in    two   lengths,  6^    and 
8  inches. 

The  Author's  Pocket  Case  Needle  Holder,  as  described  by  figure  765, 
was  designed  for  pocket  case  use.  Heretofore  nearly  all  of  the  smaller 
needle  holders  were  either  mere  toys  or  were  too  bulky  for  practical  use. 


Figure  "65.    Author's  Pocket  Case  Needle  Holder. 

The  above  pattern  is  as  small  and  compact  as  is  consistent  with  the  requisite 
strength.  The  jaws  are  of  the  improved  device,  shown  by  figure  753,  while 
the  catch  of  the  handles  is  adjustable  to  different  sized  needles.  All  the 
parts  are  separable  for  cleaning.  The  length  is  4^  inches. 

Whitney's  Needle  Holder,    as  drawn  in    figure  766,   represents  a   more 
bulky  and  stronger  holder  than  the  one  last  described.       Being  supplied 


Figure  766.    Whitney's  Needle  Holder. 

with  short,  strong  jaws,  the  instrument  possesses  considerable  strength. 
The  catch  is  adjustable  to  different  sizes  of  needles.  The  length  is  5 
inches. 

Abbe's   Needle   Holder,  as  delineated   in   figure    767,  exhibits  a  cheap, 
yet  quite  effective  pattern,  particularly  for  such  superficial  work  as  is  usually 


Figure  767.    Abbe's  Needle  Holder  and  Artery  Forceps. 

met  with  in  emergency  cases.  The  forceps  blades  are  strong,  and  as  the 
jaws  are  short,  a  needle  may  be  held  with  a  firm  grasp.  Its  length  is 
4  inches. 


Figure  768.    Hagedorn's  Small  Needle  Holder. 


Hagedorn's    Needle    Holder,   as    traced    in    figure    768,    is    particularly 
designed  for  holding  the  flat  needles  of  Hagedorn.       The  instrument  is  so 


344  MINOR    OPERATIVE    SURGERY. 

constructed  that  considerable  leverage  is  obtained,  thus  affording  a  strong, 
firm  grip.  It  may  be  said  to  be  the  standard  holder  for  needles  of  this 
pattern.  The  breadth  of  the  handle  affords  a  firm  grip,  while  the  narrow 
distal  end  occupies  little  space,  an  advantage  if  required  for  use  in  a  close 
cavity.-  It  is  usually  manufactured  in  two  lengths,  6  and  8  inches. 

Ligature  Scissors. 

Gusserow's  Ligature  Scissors,  as  shown  in  figure  769,  are  especially  con- 
structed for  cutting  non-metallic  sutures.     The  lower  blade  terminates  in  a 


Figure  769.    Gusserow's  Ligature  Scissors. 

prong  small  enough  to  hook  under,  and  yet  large  enough  to  prevent  the 
suture  from  slipping.  In  cases  where  sutures  are  drawn  tight,  this  instru- 
ment will  be  found  valuable.  Its  length  is  8}4  inches. 

Silver  Wire  Needles  and  Appliances. 

Suturing  with  wire  requires  some  or  all  of  the  following  instruments: 
Special  needles,  clamps  for  holding  ends  of  suture  together,  shot  com- 
pressor, shot  perforator,  wire  twister,  wire  shoulderer  and  wire  cutter. 

Silver  Wire  Needles.  To  introduce  silver  wire  by  the  aid  of  a  needle 
of  the  ordinary  surgical  type  would  require  not  only  one  of  large  dimen- 
sions, but  the  exercise  of  an  excessive  amount  of  force.  A  large  needle 
would  be  necessary  on  account  of  the  unyielding  nature  of  the  wire, 
which  will  not  flatten  as  do  non-metallic  sutures  when  the  attempt  is 
made  to  draw  it  through  the  oval  eye  of  a  plain  surgical  needle.  A  greater 
force  would  be  required  because  wire  will  not  bend  as  abruptly  as  softer 
sutures.  As  it  can  not  be  curved  sharply  upon  itself  at  the  points  of  its 
exit  from  the  needle  eye,  it  forms,  with  the  shaft  of  the  needle,  a  mass  too 
thick  to  be  easily  drawn  through  the  needle  opening.  It  has,  therefore, 
been  the  practice  among  many  surgeons  to  first  introduce  a  silk  thread, 
using  an  ordinary  surgical  needle,  and  thus  form  a  track  or  opening  for 
the  proposed  wire  suture.  The  wire  in  such  cases  is  drawn  through  the 
wound  margins  by  attaching  it  to  the  silk  thread  previously  introduced. 
This  condition  has  led  to  the  construction  of  special  needles  of  various 
styles  for  the  direct  introduction  of  wire  sutures.  These  are  of  two  classes, 
solid  and  canulated. 

Solid  Needles  for  silver  wire  comprise  those  patterns  that  are  provided 
with  means  by  which  they  may  be  attached  directly  to  the  wire. 

Lister's  Silver  Wire  Needle,  as  pictured  in  figure  770,  represents  the 
most  simple,  and  we  believe  the  oldest  form  of  this  class  of  needles.  It 
differs  from  the  ordinary  pattern  in  being  provided  with  a  groove  that 
extends  from  the  eye  of  the  needle  upon  each  side  backward  to  its  base, 
which  serves  to  receive  the  wire,  thus  reducing  the  thickness  of  the  mass. 


SILVER    WIRE    NEEDLES    AND    APPLIANCES. 


345 


The  Silver  Wire  Needle,  with  screw  socket,  as  portrayed  in  figure  671, 
is  a  plain  pattern  without  eye,  but  provided  instead  with  a  socket  in  its  base, 
in  which  is  cut  the  female  thread  of  a  screw.  To  attach  a  silver  wire 
suture  to  this  needle  it  is  necessary  only  to  select  a  needle  having  a  socket 
slightly  smaller  than  the  wire  to  be  employed,  when  by  slightly  tapering 


Figure  770.    Lister's  Silver  Wire  Needle. 


Figure  771.    Silver  Wire  Needle  with 
Screw  Socket. 


Figure  772.    German  Silver  Wire  Needles. 


the  end  of  the  latter,  it  may  be  screwed  into  the  needle,  forming  a  union 
strong  enough  for  the  service  required.  As  the  wire  is  soft,  the  thread 
formed  in  the  steel  needle  cuts  a  screw  on  the  wire,  so  that  no  further 
preparation  of  the  wire  is  necessary. 

The  German  Silver  Wire  Needle,  as  defined  by  figure  672,  illustrates  the 
application  of  a  new  principle  in  attaching  a  wire  to  a  needle.  The  lower 
end  or  base  of  this  needle  is  hollow  or  tubular  and,  as  shown  by  "A"  in  the 


Figure  773.    Stone's  Canulated  Needle. 

illustration,  is  provided  with  a  small  oval  opening  connecting  with  the 
lumen  of  the  tube.  To  thread  this  needle  for  use,  the  operator  has  only  to 
pass  the  wire  into  the  opening  at  the  base  and  out  through  the  orifice  at 
the  side  where  the  extreme  end  may  be  bent  or  curved  upon  itself,  as 
shown  by  "B,"  after  which  it  may  be  drawn  backward  into  the  body  of  the 
needle,  as  shown  by  "C."  The  doubled  portion  being  of  greater  diameter 
than  the  lower  opening,  the  needle  is  in  no  danger  of  being  separated  from 
the  wire.  They  can  be  procured  either  straight,  half  curved  or  full  curved. 


C 


Figure  774.    Von  Bruns'  Canulated  Needles. 

Canulated  Silver  Wire  Needles.  These  are  constructed  from  steel  tub- 
ing, pointed  like  an  aspirating  needle  and  are  so  designed  that  after  the 
needle  has  been  passed  through  the  tissues  to  be  sutured,  the  wire  may 
be  pushed  through  the  needle  canula,  where  it  may  be  grasped  and  held,  so 
that  after  withdrawal  of  the  needle  the  wire  will  remain  in  situ. 

Stone's  Canulated  Needle,  as  shown  by  figure  773,  is  perhaps  the  most 
simple  of  its  kind.  It  consists  of  a  plain  tube  about  4  inches  in  length, 
attached  to  a  suitable  handle,  the  whole  having  a  length  of  about  8  inches. 


346 


MINOR    OPERATIVE    SURGERY. 


Von  Brims'  Canulated  Needles,  as  pictured  in  figure  774,  consist  of  a 
set  of  two  or  three  needles,  each  attached  to  a  handle  by  a  screw.  One 
needle  is  slightly,  the  others  curved.  The  length  is  about  7  inches. 

Collins'  Set  of  Canulated  Needles,  as  illustrated  in  figure  775,  consists 
of  six  needles  of  various  shapes,  all  easily  attached  to  a  suitable  shank  and 
handle.  The  shank  is  tubular  and  so  adjusted  as  to  form  a  perfect  connec- 


Figure  775.    Collins'  Set  of  Canulated  Needles. 


tion  with  any  one  of  the  six  needle  points  that  may  be  connected  for  use. 
The  wire  in  passing  forward  through  the  shank  and  needle  is  directed 
beneath  the  milled  edge  of  a  small  wheel  so  fixed  upon  a  spring  that  it 
may  be  pressed  down  upon  the  wire.  This  wheel  is  used  to  feed  the  wire 
through  the  needle,  by  turning  with  the  thumb. 

Silver  "Wire  Clamps  and  Shields. 

These  may  consist  of  perforated  shot  or  buttons. 

A  Perforated  Shot,  as  shown  in  figure  777,  furnishes  the  best  means  for 
clamping  the  ends  of  a  wire  suture.  To  secure  the  ligature  against  slip- 
ping, it  is  necessary  only  to  thread  or  pass  the  ends  through  the  opening  in 
the  shot,  push  the  latter  down  or  along  the  wire  as  far  as  is  necessary  to 


Figure  776. 
Getch  ell's  But- 
ton. 


Figure  777.    Perforated  Shot. 


Figure  778.    Lead  Button. 


Figure  779.    Powell's  Button. 


obtain  sufficient  tension  on  the  parts  involved  in  the  suture,  and  with  a 
short  forceps  with  strong  jaws  compress  the  shot  until  it  firmly  grips  the 
suture  ends.  To  make  certain  that  slipping  will  not  occur,  a  second  shot 
is  often  employed,  which  is  forced  tightly  down  against  the  first  one. 

Silver  Wire  Buttons  are  employed  to  prevent  a  suture  under  heavy  strain 
from  cutting  through,  or  into  the  underlying  tissues. 

Getchell's  Button,  as  displayed  in  figure  776,  is  manufactured  from  lead, 
Brittania,  or  such  other  soft  metal  as  may  be  easily  compressed.  When  in 
use,  the  suture  ends  are  passed  upright  through  the  vertical  shaft,  the 
button  slipped  into  place  and  the  shaft  compressed  with  a  forceps,  the  same 
as  a  perforated  shot.  This  button  acts  both  as  a  clamp  and  as  a  protection 
against  the  cutting  of  a  suture  into  the  parts  involved. 

The  Lead  Button,  shown  in  figure  778,  may  be  either  round  or  oval. 
It  is  employed  in  inserting  retention  sutures,  for  instance,  those  of  the 
Lister  type.  In  the  use  of  this  button,  the  suture  is  previously  prepared 
by  being  armed  with  a  shot,  tightly  clamped  at  its  distal  end.  The  button 
is  then  slipped  upon  the  ligature,  the  suture  passed  and  the  needle  un- 
threaded. Over  the  loose  ends  of  the  ligature,  a  second  button  is  now 
slipped,  followed  by  a  shot.  The  ligature  may  then  be  tightly  drawn  and 


SILVER    WIRE    NEEDLES    AND    APPLIANCES.  347 

clamped.  These  buttons  may  be  purchased  ready  for  use  or  may  be  cut 
with  a  pair  of  scissors  from  heavy  sheet  lead.  In  ordering  material  from 
which  to  cut  buttons  of  proper  thickness,  the  surgeon  should  specify 
"Suction  Lead." 

Powell's  Suture  Button,  as  illustrated  by  figure  779,  are  made  from 
pure  block  tin.  A  central  post  arises  from  a  base  to  a  height  of  T3^  inch, 
perforated  with  a  round  hole  from  the  under  surface  of  the  plate  to  its  own 
apex.  This  post  is  cross-cut  down  to  the  shoulder.  In  using  these  appli- 
ances, the  wire  or  thread  is  passed  through  from  below,  bent  into  the  slot, 
wound  two  or  more  times  around  the  post,  and  then  carried  across  the  post 
through  the  slot  again.  They  are  equally  well  adapted  for  use  with  silk- 
worm gut,  catgut,  silk  or  wire.  They  can  be  bent  to  fit  irregular  surfaces, 
instantly  fastened,  unfastened,  tightened  or  relaxed,  and  cannot  slip  or 
break 

Shot  Perforators. 

While  shot  may  be  purchased  in  various  sizes  already  perforated,  the 
surgeon  who  uses  it  in  large  quantities  will  find  it  profitable  to  supply 
himself  with  some  form  of  perforator  and  either  punch  the  openings  him- 
self, or  entrust  it  to  an  assistant. 

These  shot-perforating  forceps  are  constructed  in  such  a  manner  that 
one  jaw  serves  to  hold  or  steady  the  shot,  while  it  is  perforated  with  the 
other. 

The  Author's  Shot-Perforating  Forceps,  shown  in  figure  780,  practically 
consists  of  a  flat  nosed  plier,  one  jaw  of  which  contains  a  cylindrical  shot 


Figure  780.    Author's  Shot-Perforating  Forceps. 

holder,  while  the  other  is  supplied  with  a  small  punch  with  which  the  shot 
may  be  perforated.  The  cylinder  is  closed  at  one  end  with  an  inner  diam- 
eter, a  trifle  larger  than  the  shot,  and  near  its  closed  end  is  provided  with 
a  lateral  opening  that  admits  the  perforating  punch.  When  in  service,  the 
forceps  are  held  so  that  the  mouth  of  the  cylinder  is  upward,  the  jaws  allowed 
to  open,  the  shot  dropped  into  the  cylinder,  the  forceps  closed,  and  the  per- 
foration accomplished,  when  by  turning  the  forceps  over,  the  shot  will  drop 
from  the  cylinder.  This  simple  contrivance  will  enable  surgeons  to  per- 
forate shot  without  relying  on  dealers  for  supplies. 

Shot-Compressing  Forceps. 

Perforated  shot  may  be  compressed  with  almost  any  forceps  constructed 
with  a  short,  strong  jaw. 

Thomas'  Shot-Compressing  Forceps,  as  designated  by  figure  781,  repre- 
sents the  standard  instrument  for  performing  this  service.  They  consist  of 


348 


MINOR    OPERATIVE    SURGERY. 


plain  ring  handle  forceps,  with  long,  heavy  handles  and  short,  strong  jaws. 
That  the  latter  may  engage  the  shot  without  danger  of  slipping,  the  inner 
surfaces  of  the  jaws  are  covered  with  fine  transverse  serrations,  which  will 
not  cut  the  shot  or  roughen  its  outer  surface,  thus  decreasing  its  clamping 


Figure  781.    Thomas'  Shot  Compressing  Forceps. 


power  and  rendering  it  an  unfit  substance  to  come  in  contact  with  soft  or 
mucous  surfaces.     The  forceps  are  8  inches  in  length. 

Wire-Twisters. 

These  are  employed  to  clamp  together  or  otherwise  hold  the  ends  of  a 
wire  suture  and  twist  them  into  a  single  strand,  thus  securely  fastening  the 
two  together.  They  are  of  two  varieties,  wire  twisting  forceps  and  rotating 
twisters. 

Wire-Twisting  Forceps  usually  consist  of  some  form  of  a  slide- catch 
forceps  of  extra  length.  The  operation  requires  only  a  limited  amount  of 
force,  thus  admitting  the  use  of  a  slender  instrument. 

Nott's  Wire-Twisting  Forceps,  as  represented  in  figure  782,  are  simi- 
lar to  the  old  style  double  slide-catch  torsion  hemostatic  forceps,  dif- 


Figure  782.    Nott's  Wire-Twisting  Forceps. 

fering  from  it  only  in  length.  The  slide  operated  by  a  thumb-piece 
terminates  in  two  clamps  or  catches,  each  traveling  in  a  slot  cut  on  an 
incline  on  both  lateral  aspects  of  the  lower  blade.  The  jaws  are  trans- 
versely serrated  to  afford  sufficient  grip  to  hold  the  wire.  The  length  is 
8  inches. 

Emmet's  Twisting  Forceps,  as  indicated  in  figure  783,  are  constructed 
on  the  same  general  plan  as  Nott's.  The  principal  point  of  difference  is  the 
shape  of  the  jaws,  which  are  here  enlarged  into  two  hemispheres,  the  plane 


Figure  783.    Emmet's  Twisting  Forceps. 

between  them  being  finely  grooved,  one  transversely  and  the  other  stel- 
lated. It  thus  presents  a  larger  grasping  surface,  the  delicate  corruga- 
tions preventing  the  wire  from  slipping  from  between  the  jaws.  The 
length  is  8  inches. 


SILVER    WIRE    NEEDLES    AND    APPLIANCES. 


349 


Rotating  Twisters  are  less  complicated,  and,  we  believe,  more  easily 
manipulated  than  wire-twisting  forceps.  With  them  the  sutures  may  be 
drawn  closely  together  before  the  twisting  is  commenced,  and  there  is 
less  tendency  for  the  wires  to  slip  out  of  the  grasp  of  the  instrument. 

The  Plain  "S"  Wire  Twister,  as  explained  by  figure  784,  illustrates  one 
of  the  simplest  and  most  satisfactory  of  the  wire-twisting  implements.  It 


Figure 


Plain  "  S  "  Wire  Twister. 


consists  of  a  plain  handle  and  shaft,  terminating  in  an  S-shaped  clamp, 
fastened  to  the  stem  at  its  center  and  so  adjusted  that  its  axis  is  at  right 
angles  with  the  shaft  of  the  instrument. 

To  operate  it  the  surgeon  grasps  the  ends  of  the  suture  to  be  twisted 
and  passes  each  into  or  through  the  incomplete  loop  of  the  "S"  clamp,  and 
slides  the  latter  along  the  wires  until  the  point  is  reached  where  the  wires 
should  be  united  into  the  twisted  strand,  when,  by  simple  rotation  of  the 
handle,  without  risk  of  the  slipping  of  one  or  both  wires  from  the  instru- 
ment, union  is  effected.  A  further  advantage  may  be  secured  by  maintain- 
ing a  firm  grip  on  the  wire  ends  \vith  the  fingers  after  the  twister  is  in  posi- 
tion and  during  the  first  turn  or  two,  as  the  tension  can  then  be  accurately 
adjusted.  Its  regular  length  is  8  inches. 

Classen's  Wire  Twister,  as  delineated  in  figure  785,  is  claimed  to  be  an 
improvement  upon  the  plain  instrument  last  described. 

The  handle  is  a  spiral  wire  cable,  the  grooves  in  the  cable  being  deep 
enough  to  give  movement  to  a  close-fitting  running  collar  that  is  made  to 


Figure  785.     Classen's  Wire  Twister. 


travel  back  and  forth  along  the  cable.  The  handle  end  terminates  in  a 
revolving  ring,  while  the  distal  end  is  supplied  with  an  "S"  bar,  as  before 
described.  By  placing  the  thumb  in  the  proximal  ring  and  the  first  and 
second  finger  in  the  rings  attached  to  the  moving  collar,  the  shaft  may  be 
rotated  evenly  and  either  fast  or  slow  as  desired.  Its  length  is  9  inches. 

"Wire-Shouldering-  Forceps. 

While  it  is  comparatively  easy  to  insert  ordinary  sutures  without  pucker- 
ing the  surface  and  producing  linear  construction,  this  is  not  so  easily 
accomplished  with  silver  wire,  because  the  stiffer  the  suture,  the  more  it  is 


Figure  786.    Thomas'  Shouldering  Forceps. 

inclined  to  draw  tightly  upon  the  external  aspect  without  closing  in  the 
deeper  portions  of  the  wound.  For  this  reason  wounds  may  be  imperfectly 
united  when  the  larger  sizes  of  silver  wire  are  used. 


350  MINOR    OPERATIVE    SURGERY. 

Thomas'  Wire  Shouldering  Forceps,  as  shown  in  figure  786,  are  used  in 
spreading  and  holding  the  strands  apart  while  being  twisted.  If  traction 
be  made  on  the  wires  while  being  twisted,  as  they  pass  over  the  separated 
blades  of  the  forceps,  the  deeper  wound  margins  may  be  drawn  into  close 
approximation,  after  which  any  degree  of  tension  desired  may  be  applied 
to  the  surface. 

Silver  "Wire  Cutters. 

While  silver  wire  can  be  cut  with  ordinary  surgical  scissors,  it  is  not 
only  damaging  to  the  cutting  edges,  but  unless  specially  constructed  for 
this  purpose,  the  blades  are  usually  too  long  to  afford  sufficient  leverage 
and  too  large  to  be  slipped  underneath  a  small  suture. 

Tucker's  Wire  Cutter,  as  pictured  in  figure  787,  consists  of  a  small  chisel 
sliding  upon  a  fixed  bar,  the  latter  being  bent  at  a  right  angle  near  its 


Figure  787.    Tucker's  Wire  Cutter. 

distal  end  to  provide  an  opposing  surface.  Between  this  and  the  chisel 
edge  the  wire  may  be  easily  cut.  The  cutting  force  is  applied  to  the 
thumb-piece,  which  requires  only  to  be  pushed  forward  to  sever  wire,  even 
of  large  size.  The  instrument  is  so  slender  it  can  easily  be  crowded  under 
a  tight  suture,  an  advantage  not  obtained  when  using  ordinary  scissors. 
Its  length  is  8  inches. 

Smith's  Wire  Cutting  Scissors,  as  illustrated  in  figure  788,  seem  to 
possess  all  the  requirements  essential  in  an  instrument  for  this  purpose. 
The  blades  are  short,  thus  possessing  good  leverage ;  slender,  that  they  may 
be  pressed  underneath  a  tight  suture ;  and  with  double  concave  cutting  sur- 


Figure  788.    Smith's  Wire  Cutting  Scissors. 

face  that  the  wire  may  not  easily  slip  from  between  the  blades  when  tightly 
compressed.     Their  length  is  6  inches. 

Dressings. 

These  consist  of  coverings,  protectives  or  supports  applied  to  diseased 
or  injured  parts.  They  are  employed  to  secure  rest,  to  hold  in  position 
parts  liable  to  misplacement,  as^a  shield  against  accidental  injury,  or  to  pre- 
vent wound  infection  and  decomposition  of  discharges.  Dressings  may  be 
classified  as  follows:  Adhesive  plasters,  absorbents,  paddings,  protectives, 
bandages  and  safety  pins  and  splints  for  general  purposes.  These  may  be 
required  singly  or  in  any  combination. 

Adhesive   Plasters. 

These  are  formed  by  spreading  upon  cloth  or  other  suitable  material,  or 
directly  upon  the  tissues,  a  substance  either  simple  or  compound,  that,  by 


DRESSINGS.  351 

heat,  moisture  or  evaporation,  will  adhere  to  the  surfaces  to  which  they  are 
applied. 

While  they  have  been  extensively  employed  in  the  past  for  holding 
together  the  margins  of  wounds,  they  are  now  rarely  utilized  except  to 
support  the  skin  and  underlying  masses  upon  either  side  of  a  wound  in 
cases  where  the  weight  of  such  tissues  would  cause  undue  tension  upon  the 
sutures,  as  a  protection  against  injury  or  wound  infection,  and  as  a  means 
to  secure  traction  in  cases  of  fractures,  joint  affections,  etc.  They  are 
occasionally  used  to  firmly  hold  in  close  contact,  margins  that  have  failed 
to  heal  by  first  intention,  and  in  cases  where,  from  the  friable  nature  of  the 
parts,  it  is  impossible  to  secure  tissues  of  sufficient  strength  to  afford  the 
necessary  resistance  to  sutures.  In  all  cases  where  plasters  are  employed, 
care  must  be  taken  to  prevent  infection  of  the  wound  from  them.  If  there 
be  hairs  upon  the  surface  to  be  covered,  they  should  first  be  removed  with 
a  razor,  for  traction  on  them,  either  by  the  slipping  or  stretching  of  the 
plaster  while  in  service  or  during  its  removal,  may  cause  the  patient  much 
pain  and  discomfort. 

Plasters  should  be  applied  only  to  clean,  dry  surfaces.  If  the  skin  is 
well  scrubbed,  and  if  the  plaster  is  of  good  quality  and  carefully  pressed 
in  close  contact,  it  will  sustain  considerable  force.  Where  reapplied  in 
cases  of  traction,  etc.,  the  dead  scarf  skin  should  first  be  removed.  They 
should  never  be  applied  direct  to  abraded  or  raw  surfaces.  In  removing 
a  plaster  it  should  be  stripped  up  to  the  wound  from  both  ends,  otherwise 
traction  will  be  made  by  one-half  of  the  strip  in  a  direction  that  will  tend  to 
reopen  the  wound.  The  adhesive  plasters  in  common  use  are  known  as 
resin,  rubber,  isinglass,  soap  and  collodion  plasters. 

Resin  Adhesive  Plaster  is  the  Emplastrum  Adhesivum  of  the  United 
States  Pharmacopeia,  prepared  from  resin,  wax,  etc.,  the  mixture  being 
spread  upon  muslin  cloth.  For  use  the  strips  should  be  cut  lengthwise  of 
the  roll,  as  there  is  less  tendency  to  stretch  in  this  direction.  This  plaster 
adheres  after  being  heated,  the  best  method  being  to  apply  the  back  or 
unspread  surface  to  a  vessel  of  hot  water,  or  it  may  be  held  over  a  stove, 
the  flame  of  a  spirit  lamp,  etc.  It  must  not  be  applied  too  hot,  as  the  heat 
might  destroy  the  epidermis,  and  thus  allow  the  skin  to  peel  off  and  the 
plaster  loosen.  The  spread  surface  is  usually  covered  with  a  layer  of  tissue 
paper,  which  must  be  removed  before  application.  This  plaster  is  largely 
used  for  making  extensions,  for  strapping  in  cases  of  fractures,  and  for  sup- 
porting redundant  flaps  and  parts  following  operation.  It  is  of  an 
emollient  soothing  nature,  which  renders  it  adaptable  for  use  on  children 
and  patients  with  tender  skins,  in  cases  where  a  rubber  plaster  causes  irri- 
tation and  discomfort. 

Moleskin  and  swansdown  plasters  are  heavier  grades  of  resin  plaster, 
spread  on  stronger  cloth,  the  latter  with  a  soft  wax  on  the  unspread  side. 
The  adhesive  mixture  is  the  same  as  that  used  in  the  regular  resin  plaster, 
the  only  difference  being  in  the  material  upon  which  it  is  spread.  Good 
canton  flannel  is  used  in  the  manufacture  of  both,  a  quality  with  a  short 
nap  being  employed  for  the  first,  and  with  an  extra  heavy  long  nap  for  the 
other. 

Rubber  Adhesive  Plaster  is  employed  for  the  same  purposes  as  the 
resin  plaster  before  described.  It  requires  no  other  heat  to  ensure  its 
adhesion  than  that  furnished  by  the  body  of  the  patient,  although,  if  slightly 
warmed  before  application,  it  will  become  fixed  more  quickly.  As  it  will 
not  adhere  to  a  wet  surface,  the  surface  must  be  dry  before  it  is  applied. 

L_LIEI£L 


352 


MINOR    OPERATIVE    SURGERY. 


It  is  impervious  to  water,  and  when  wet  does  not  become  loosened.  It 
may,  perhaps,  be  well  to  remember  that  rubber  plasters  may  be  removed 
without  difficulty  if  moistened  with  benzine.  Owing  to  the  peculiar 
nature  of  the  plaster  mass  employed  in  its  manufacture,  a  thin  layer  of  the 
cementing  substance  answers  as  well  as  the  thicker  coats  on  the  resin 
plasters.  It  is  much  thinner  and  more  pliable  than  the  latter,  thus  enabling 
the  operator  to  more  easily  adjust  it  over  uneven  surfaces. 

As  its  name  implies,  it  is  composed  partially  of  India  rubber,  the  pure 
Para  variety  being  employed  in  its  manufacture.  In  its  preparation  the 
crude  rubber  is  macerated  and  steeped  in  hot  water  baths,  both  acid  and 
alkaline,  until  it  becomes  soft  and  neutral,  after  which  it  is  repeatedly 
passed  between  corrugated  or  toothed  rolls,  so  closely  adjusted  as  to  act  as 
a  mixer  or  crusher.  This  process  is  continued  until  the  rubber  is  worked 
into  a  soft  elastic  mass,  after  which  it  is  reduced  to  thin  sheets  and  thor- 
oughly washed  until  all  dirt  and  foreign  matter  are  removed.  These  sheets 
are  then  dried  by  the  aid  of  steam  coils,  after  which  the  gums,  resin,  wax, 
etc. ,  are  mixed  with  the  rubber  by  means  of  a  special  grinding  machine 
composed  of  heavy  steel  rollers,  through  which  the  mass  is  repeatedly 
passed  until  all  the  materials  are  thoroughly  incorporated  together. 

Orris  root  is  usually  mixed  with  the  other  ingredients  for  the  purpose  of 
disintegrating  the  rubber  fibers  and  giving  the  proper  consistency  to  the 
entire  mass.  As  an  antiseptic,  and  to  prevent  decomposition,  boric  or 
salicylic  acid  is  usually  incorporated  with  it.  The  mass  thus  prepared  is 
spread  on  strong  cotton  cloth  by  means  of  a  special  machine,  the  principal 
feature  of  which  is  three  massive  steel  rollers.  The  cloth  usually  employed 
is  36  inches  in  width,  and  as  it  passes  between  the  steel  rollers,  the  mass  is 


Figure  789.    Spool  of  Rubber 
Adhesive  Plaster. 


Figure  790.     Roll  of  Isinglass  Adhesive  Plaster. 


fed  by  a  special  arrangement,  spreading  it  upon  the  cloth  to  any  desired 
thickness.  The  spread  plaster  after  passing  through  the  machine  is  reeled 
on  large  cylinders,  each  successive  layer  being  separated  from  the  preceding 
one  by  strips  of  board,  so  arranged  that  the  layers  do  not  touch  each  other. 
After  drying  a  sufficient  length  of  time,  the  plaster  is  unwound  and  its 
face  covered  with  cheese  cloth  or  other  fabric,  after  which  it  is  tightly 
wound  on  wooden  cylinders,  upon  which  it  is  cut  by  circular  revolving  knives 
into  strips  of  any  desired  width.  The  strips  are  then  transferred  to  a  table, 
cut  into  lengths  as  desired,  and  wound  on  spools  or  into  rolls  for  the  market. 

Rubber  adhesive  plaster,  as  usually  found,  may  be  purchased  in  one- 
yard  rolls,  7  inches  wide ;  in  five-yard  rolls,  7  and  1 2  inches  wide,  and  in  ten- 
yard  rolls,  as  shown  in  figure  789,  ^,  i,  \%,  2,  2^  and  3  inches  wide. 

This  plaster  mass  is  also  spread  on  strong  canton  flannel,  the  same  as  the 
moleskin  and  swansdown  resin  plasters.  This  form  may  be  procured  in 
yard  rolls,  j  or  12  inches  wide. 

iO    HfjHJJOrj 

gHf= 


DRESSINGS.  353 

Isinglass  Adhesive  Plasters  are  manufactured  by  spreading  upon  silk, 
muslin,  tracing  cloth,  goldbeaters'  skin,  leather,  etc.,  a  solution  formed  by 
dissolving  Russian  isinglass  in  distilled  water.  Some  manufacturers  add 
to  this  solution  a  small  percentage  of  salicylic  acid  and  alcohol.  These 
plasters  adhere  by  moisture ;  that  is,  by  slightly  wetting  them.  They  are 
convenient  for  treating  superficial  wounds,  particularly  those  of  a  slight 
nature,  especially  in  cases  where  they  can  be  kept  perfectly  dry.  Unless 
applied  over  an  intact  surface,  they  should  be  moistened  with  an  antiseptic 
solution.  Isinglass  plasters  may  be  procured  in  the  following  varieties : 
Muslin,  moleskin,  tracing  cloth,  silk  (court  plaster),  goldbeaters'  skin  and 
kid. 

Muslin  Isinglass  Plaster  is  spread  upon  ordinary  muslin,  and  is  the 
form  most  commonly  in  use  by  surgeons.  It  may  be  obtained  in  spools 
ten  yards  in  length,  ^,  i,  2  and  3  inches  in  width;  in  rolls  one  yard  long 
and  8  inches  in  width,  as  shown  in  figure  790 ;  and  in  rolls  five  yards  in  length 
and  1 1  inches  in  width. 

Moleskin  Isinglass  Plaster,  as  usually  found  in  the  market,  is  spread 
upon  canton  flannel  similar  to  that  employed  in  the  manufacture  of  mole- 
skin resin  plaster.  Like  the  latter  preparation,  it  is  sometimes  employed  in 
cases  where  a  surface  easily  irritated  will  not  permit  the  use  of  the  rubber 
or  combination  plasters. 

Tracing  Cloth  Isinglass  Plaster,  as  its  name  implies,  is  spread  upon  the 
tracing  cloth  used  by  architects.  This  cloth,  though  thin  in  substance 
(being  glazed  upon  both  sides),  presents  a  smooth,  firm,  unyielding  surface, 
which  adapts  it  for  use  as  a  plaster  base  in  certain  classes  of  cases.  It 
may  be  obtained  white,  black  or  flesh  color,  and  is  usually  found  in  one 
yard  rolls,  7  inches  in  width.  It  is  frequently  sold  as  a  cheap  quality  of 
court  plaster.  • 

Silk  Isinglass  Plasters  are  spread  upon  Marceline  silk,  and  possess  the 
advantage  of  being  thin  and,  when  moistened  for  application,  soft  and 
pliable.  This  material  forms  the  ordinary  court  plaster  of  the  market. 
They  may  be  obtained  in  a  great  variety  of  forms,  and  for  surgical  use  may 
be  obtained  in  rolls  one  yard  in  length,  7  inches  in  width,  and  in  various 
colors,  such  as  white,  black,  green  and  flesh  color. 

Goldbeaters'  Isinglass  Plaster  forms  the  thinnest  of  all  the  adhesive  plas- 
ters, as  it  is  but  little  thicker  than  tissue  paper.  It  is  made  by  spreading 
the  isinglass  solution  upon  a  special  animal  tissue  (the  prepared  peritoneal 
membrane  of  the  cecum  of  the  ox),  manufactured  for  the  use  of  gold- 
beaters, from  which  it  takes  its  name.  It  is  frequently  applied  to  burnt  and 
scalded  surfaces  and  in  cases  where  a  smooth  covering  to  an  unbroken  skin 
surface  is  required. 

Kid  Isinglass  Plaster  is  manufactured  by  spreading  the  isinglass  solution 
on  split  sheepskin  or  similar  leather.  Its  only  advantages  are  its  thick- 
ness and  water-proof  qualities.  It  is  sometimes  used  as  a  protective 
against  the  confined  pressure  of  splints,  braces  and  other  similar  appliances. 
It  may  be  purchased  in  rolls  one  yard  in  length  and  7  inches  in  width. 

Soap  Plaster  is  manufactured  by  spreading  emplastrum  saponis  on  soft 
leather,  such  as  chamois,  kid,  or  split  sheepskin.  Strictly  speaking,  it  is 
more  of  a  protective  than  a  strapping  plaster,  as  its  principal  use  is 
to  afford  protection  or  adhesive  covering  to  salient  parts  submitted  to 
long-continued  or  undue  pressure.  It  is  used  to  abort  threatened  cases  of 
decubitus,  and  may  be  applied  to  any  part  of  the  body  for  protective  pur- 
poses. 

23 


354  MINOR    OPERATIVE    SURGERY. 

Collodion  Plaster. 

Collodion  is  frequently  employed  as  an  occlusion  wound  dressing,  and 
as  a  means  of  preventing  wound  infection  after  an  operation.  It  consists  of 
a  strip  of  antiseptic  gauze,  large  enough  to  cover  the  wound  and  immedi- 
ately surrounding  parts,  saturated  with  some  form  of  collodion.  This  may 
be  poured  upon  the  gauze,  or  smoothed  over  and  pressed  against  the  tissues 
with  a  glass  spatula,  or  it  may  be  painted  on  with  a  brush  kept  for  such 
purpose.  Many  operators  incorporate  bichloride  of  mercury  with  collodion, 
forming  a  mixture  known  as  bichloride  collodion. 

Absorbent   Dressings. 

These  are  utilized  to  absorb  excretory  matter,  to  prevent  its  decomposi- 
tion, and  to  protect  wounds  against  the  entrance  of  pathogenic  micro- 
organisms. Such  materials  should  be  aseptic,  soft  and  pliable,  non-irritat- 
ing, easy  of  application,  and  of  good  absorbent  qualities.  The  substances 
usually  employed  are  gauze,  absorbent  cotton,  lint,  absorbent  wool,  wood 
wool,  moose  pappe,  and  spongiopiline. 

Gauze  is  a  loosely  woven  cotton  fabric,  manufactured  from  a  fine,  tightly- 
twisted  thread.  For  surgical  purposes  it  is  prepared  from  the  ordinary 
cheese  cloth  of  the  market.  Having  an  open  mesh,  when  absorbent,  it 
possesses  considerable  power  of  capillary  attraction.  This  quality  makes  it 
suitable  for  receiving  and  absorbing  wound  discharges,  and  renders  it  easy 
of  medication.  Before  application  it  is  sometimes  sterilized  or  impregnated 
with  antiseptics. 

It  is  prepared  by  boiling  in  a  strong  alkaline  solution,  by  which  process 
all  oily  matters  are  removed,  after  which  it  is  bleached,  washed,  dried, 
ironed  and  wound  into  rolls  of  different  sizes  and  lengths.  In  this  condition 
it  is  known  as  "absorbent  gauze,"  and  from  this  the  various  antiseptic  prep- 
arations are  manufactured. 

Sterilized  Gauze,  while  it  will  not  absorb  as  large  a  proportion  of  fluids 
as  will  various  similar  substances  utilized  for  the  same  purpose,  possesses 
some  advantages  not  found  in  other  articles.  Unlike  sponges,  its  particles 
are  coherent,  and  there  is  no  danger  of  fibers  or  pieces  breaking  away  from 
the  mass  and  thus  becoming  lost  within  the  labyrinths  of  a  wound.  As  it 
possesses  good  absorbing  powers,  it  forms  a  fairly  good  substitute  for 
sponge ;  as  it  has  a  tendency  to  dry  quickly,  it  becomes  an  auto-destroyer  of 
microbic  life,  and  whether  saturated  or  dry,  forms  a  soft,  plastic  mass, 
easily  manipulated. 

In  the  application  of  gauze  as  a  dressing,  it  is  well  to  remember  that  if 
sterile  and  absolutely  dry,  it  can  not  be  diverted  into  a  breeding  ground  for 
bacteria.  One  of  the  necessary  elements  to  germ  life  is  moisture,  and  for 
this  reason  the  nearer  a  dressing  is  free  from  it,  the  better.  Many  oper- 
ators insist  upon  medicating  gauze,  cotton  and  other  absorbents  with  some 
form  of  chemical  germicide,  believing  that  by  so  doing  they  either  prevent 
the  decomposition  of  wound  discharges,  or  furnish  an  antiseptic  of  material 
benefit.  We  believe  that  the  general  use  and  expense  of  such  medication 
are  unnecessary.  Dry,  sterile,  hygroscopic  gauze  will,  we  believe,  accomplish 
as  good  results  as  will  any  medicated  variety  (with  possibly  the  exception  of 
iodoform),  no  matter  what  the  impregnating  chemical  may  be.  Further  than 
this,  the  presence  of  a  foreign  substance  in  the  gauze  fibers  decreases  its 
absorbent  powers,  to  say  nothing  of  the  dangers  of  infection  in  the  handling 
and  packing  of  medicated  gauze  by  manufacturers  and  their  assistants, 
who  know  little  of  the  value  or  requirements  of  surgical  disinfection. 


DRESSINGS. 


355 


When  required  as  a  dressing  for  infected  wound  openings,  it  may,  if 
desired,  be  impregnated  at  the  time  of  application  with  iodoform,  corrosive 
sublimate,  boric  acid,  salicylic  acid,  etc.  With  the  exception  of  the  first 
mentioned,  all  are  medicated  by  immersion  in  a  solution  of  the  chemical 
employed.  lodoform  gauze  may  be  prepared  by  sprinkling  the  iodoform 
on  the  surface  of  the  cloth  and  then  rubbing  or  "dry- washing"  it  in,  or  a 
similar  result  may  be  obtained  by  immersing  the  gauze  in  a  solution  of 
iodoform.  For  this  purpose  an  ordinary  ethereal  solution  may  be  used,  or 
the  iodoform  may  be  included  in  a  mixture  of  water  60  parts,  alcohol  20 
parts,  and  glycerine  20  parts.  To  obtain  a  10  per  cent,  medication,  one 
pound  of  iodoform  should  be  mixed  with  as  much  of  the  above-mentioned 
mixture  as  nine  pounds  of  gauze  will  absorb. 

A  satisfactory  method  of  preparing  a  reliable  iodoform  gauze  consists  in 
loosely  rolling  nine  pounds  of  the  gauze  and  placing  it  in  a  large,  tightly- 
covered  glass  jar.  To  this  should  be  added  one  pound  of  iodoform  dissolved 
in  five  pounds  of  sulphuric  ether.  It  will  require  but  little  agitation  to 
produce  a  complete  saturation  of  the  gauze;  in  fact,  every  thread  will 


Figure  791.    Showing  Large  Roll  of  Absorbent  Gauze. 

appear  to  be  permeated  with  the  mixture.  At  the  end  of  30  minutes  the 
gauze  may  be  removed  from  the  jar,  unrolled  into  a  loose  mass,  and 
placed  in  a  willow  basket  or  other  suitable  container,  where,  after  being 
covered  with  tissue  paper  to  prevent  air  infection,  it  should  be  permitted  to 
remain  until  the  evaporation  of  the  ether,  which  will  require  from  five  to 
six  hours.  The  gauze  will  then  be  found  to  be  of  a  bluish-gray  color,  but 
by  passing  it  through  a  sublimate  solution,  i  :4ooo,  the  bright  yellow  iodo- 
form color  will  re-appear  and  the  gauze  will  thereafter  retain  its  natural 
color. 

A  difference  of  opinion  exists  as  to  the  basis  upon  which  the  percentage 
of  iodoform  contained  in  a  given  product  should  be  estimated.  Gauzes  are 
prepared  by  different  manufacturers,  moist  and  dry;  consequently  each 
may  employ  a  different  basis  for  his  calculations.  Usually  they  are  known 
as  5  and  10  per  cent,  preparations.  If  the  gauze  be  moist,  it  will  of  course 
require  a  larger  quantity  of  iodoform  to  impregnate  a  single  yard.  We 
believe  a  better  plan  is  to  estimate  the  percentage  by  weighing  the  gauze 
when  absolutely  dry.  This  is  a  standard  that,  if  adopted  by  all  manufact- 


356  MINOR    OPERATIVE    SURGERY. 

urers,  would  result  in  a  uniform  production.  For  instance,  10  pounds  of 
iodoform  would  be  incorporated  with  every  90  pounds  of  dry  gauze.  This 
would  result  in  a  10  per  cent,  preparation.  It  is  preferable,  however,  for  the 
surgeon  to  prepare  iodoform  gauze  fresh  as  wanted,  because  this  chemical 
parts  with  its  active  principles  by  age  and  exposure,  and,  by  reason  of  its 
volatile  properties,  it  is  difficult  to  sterilize. 

As  cheese  cloth,  like  ordinary  grades  of  muslin,  varies  in  quality,  it  can 
be  procured  at  different  prices.  Absorbent  gauze,  either  plain  or  medicated, 
may  be  found  in  a  great  variety  of  forms  and  sizes  of  packages,  according  to 
the  ideas  of  and  demands  upon  manufacturers.  For  emergency  use  it  may 
be  procured  in  one- quarter,  one-half  and  one  yard  packages,  each  hermeti- 
cally sealed,  the  package  being  dipped  in  melted  paraffin  •  after  wrapping. 
Five-yard  packages  may  be  purchased  in  tin  cans,  paper  cartons  or  glass 
boxes,  all  of  which  are  convenient  for  general  practice.  With  a  view  to 
economy  of  space  in  transportation  for  military  and  emergency  surgery, 
special  tightly  rolled  and  hermetically  sealed  packages  may  be  prepared. 
For  hospital  use,  rolls  of  25  to  100  yards  may  be  obtained,  thus  saving  the 
expense  of  measuring,  cutting  and  wrapping  in  smaller  packages. 


[Sterilized  Gauze. 


IhasTriiaxGreene&C0! 

•75S,77WabashAve 

CrtiC  AS-O.ILL 


Figure  792.     Showing  Individual  Package  Figure  T9&     Showing  Glass  Box  Containing 

of  Sterilized  Gauze.  5  Yards  of  Sterilized  Gauze. 

Absorbent  Cotton  is  prepared  from  the  ordinary  cotton  of  the  market 
by  a  special  process,  the  aim  of  which  is  to  separate  it  from  all  impurities, 
foreign  substances,  short  fibers,  oils,  wax,  etc. 

Cotton  in  its  natural  state  possesses  only  limited  absorbent  qualities, 
but  when  properly  prepared,  it  furnishes  for  this  purpose  one  of  the  most 
valuable  substances  in  surgery.  As  it  absorbs  liquids  freely,  it  is  largely 
employed  in  surgical  dressings.  It  is  used  in  the  various  natural  cavities 
of  the  body  to  take  up  secretions,  in  abscesses  to  absorb  pus,  to  take  up  and 
hold  excretory  liquids  of  all  forms,  and  in  many  instances  to  supply  the 
place  of  sponges.  It  is  of  a  delicate  fiber,  soft,  pliable,  and  easy  of  applica- 
tion. 

In  the  process  of  manufacture  the  crude  cotton  is  passed  through  a 
picker,  in  order  to  clean  it  from  leaves,  stems,  dirt,  etc.  Passing  from  this 
machine  in  the  form  of  laps  or  layers,  it  is  torn  into  shreds  and  conveyed  to 
a  vat  where  it  is  immersed  in  a  boiling  solution  of  caustic  soda  or  soda  ash. 
After  a  long  continued  boiling,  during  which  time  the  liquid  is  caused  to 
circulate  through  the  mass,  the  cotton  is  transferred  to  a  bleaching  tub, 
where  it  is  treated  with  chloride  of  lime  or  similar  substance,  that  all  color- 
ing matter,  stains,  etc.,  may  be  removed.  The  boiling  and  bleaching 
process  necessitates  several  washings  in  water  that  the  cotton  may  be 
thoroughly  freed  from  all  traces  of  chemicals  or  other  impurities  that  may 
have  become  incorporated  with  it.  This  is  accomplished  by  passing  it 
through  a  succession  of  baths,  in  which  soap,  neutralizing  solutions  and 
pure  water  are  freely  used.  The  last  of  these  baths  usually  consists  of  pure 


Chii  -  3    Hospi  ^al. 

DRESSINGS. 


357 


water.  Emerging  from  this,  the  mass  of  cotton  passes  between  heavy  iron 
rollers,  is  picked  into  small  pieces  by  a  machine  and  transferred  to  a  drying- 
chamber,  where  it  is  carried  upon  endless  belts  back  and  forth  for  a  long 
distance  while  subjected  to  an  atmosphere  sufficiently  high  in  temperature 
to  thoroughly  dry  it.  It  is  next  passed  through  pickers  and  lappers  where 
it  is  prepared  for  the  carding  machines.  The  latter,  if  properly  constructed, 
straighten  out  the  fibers  and  lay  them  so  far  as  possible  in  parallel  lines, 
removing  from  the  mass  the  short  staples  and  poor  particles,  and  leaving 
none  but  first-class  fibers  of  good  length  and  quality. 

A  number  of  these  carding  machines  are  usually  placed  in  a  row  and  so 
arranged  that  each  in  turn  deposits  upon  a  single,  continuous  belt  a  thin 
layer  of  cotton.  These  layers  resting  one  upon  the  other  form  the  laps  or 
folds  of  the  cotton  as  placed  upon  the  market.  If  prepared  in  this  manner, 
it  is  easy  to  separate  a  fold  of  cotton  into  thin  layers,  thus  enabling  the 
surgeon  to  sub-divide  a  package  into  thicknesses  as  required  for  use  or 
examination.  These  laps  are  rolled  into  bolts,  from  which  the  small  pack- 
ages of  the  market  are  made. 

An  important  item  in  the  manufacture  of  this  product  is  the  selection  of 
the  raw  material.  Cotton  is  valued  according  to  the  length  of  the  fiber  (or 
staple  as  it  is  commonly  called),  the  perfection  of  its  growth  and  its  cleanli- 
ness. Texas  cotton  is  usually  preferred  for  surgical  purposes,  as  the  staple 


Figure  794.    Showing  Ounce  Pack- 
age of  Sterilized  Cotton. 


Figure  795.    Showing  a  Layer  Roll  of 
Absorbent  Cotton. 


is  strong  and  of  good  length,  measuring  from  i  to  i  %  inches.  To  ascertain 
the  length  of  staple  of  a  given  sample  of  cotton,  it  is  only  necessary  to  draw 
from  the  torn  edge  of  a  lap  a  piece  such  as  may  be  grasped  between  the 
thumb  and  forefinger.  From  the  edge  of  the  torn  piece  a  layer  of  fibers 
will  protrude ;  if  this  small  bunch  of  threads  be  grasped  between  the  fingers 
and  stripped  or  drawn  from  the  detached  portion,  they  will  be  found  to  lie 
in  parallel  lines  and  easy  of  measurement. 

To  examine  cotton  to  determine  its  quality,  in  addition  to  ascertaining 
its  length  of  staple,  the  laps  or  folds  should  be  carefully  opened  or  separated 
and  each  inspected  separately.  vSome  manufacturers  "feed"  their  carding 
machines  in  such  a  way  that  the  first  and  last  of  the  line  will  furnish  cotton 
of  a  high  grade,  while  the  product  from  those  centrally  located  (the  product 
of  which  will  lie  in  the  center  of  the  bolt,  surrounded  on  both  sides  by 
material  of  a  high  grade)  will  be  inferior.  The  thin  separate  layers  of 
cotton  when  held  up  to  the  light  should  show  an  evenness  and  parallelism 
of  fiber,  and  be  free  from  white  specks. 

Inferior  qualities  of  cotton  are  usually  manufactured  from  staples  less 
than  an  inch  in  length,  or  from  the  refuse  collected  by  the  carding 
machines.  Egyptian  cotton  furnishes  a  staple  1%  to  \y2  inches  in  length, 


358  MINOR    OPERATIVE    SURGERY. 

and  as  it  is  of  a  higher  grade  than  that  of  American  growth,  it  is  pre- 
ferred by  some  operators.  Peruvian  cotton  possesses  a  staple  still  longer 
than  the  Egyptian,  but  as  it  has  an  extra  strong,  coarse  and  curly  fiber 
difficult  to  render  absorbent,  it  is  seldom  used  for  surgical  purposes. 

A  second  quality  of  cotton  known  as  "hospital  grade,"  is  manufactured 
from  the  combings  or  refuse  thrown  off  by  the  carding  machines,  some- 
times mixed  with  a  fair  percentage  of  long  fibers.  This  cotton  possesses 
fair  absorbent  qualities,  and  for  many  purposes  is  almost  as  satisfactory  as 
the  higher  grades.  As  it  can  be  procured  in  quantities  at  a  price  some- 
what less  than  that  charged  for  standard  grades,  it  is  frequently  purchased 
by  hospitals  and  public  institutions. 

Like  absorbent  gauze,  cotton  may  be  impregnated  with  antiseptics  and 
can  be  procured  in  the  market  borated,  salicylated,  sublimated,  styptic, 
etc.,  according  to  the  chemical  used  in  its  medication.  With  the  exception 
of  the  latter,  which  is  generally  put  up  in  ounce  bottles,  they  may  be  pur- 
chased in  paper  wrappers,  containing  i,  4,  8  or  16  ounces  each.  As  it 
will  not  admit  of  much  compression  without  "matting,"  the  packages  are 
usually  somewhat  bulky. 

Pratt's  Wicking  is  manufactured  as  a  substitute  for,  or  rather  an 
improvement  on,  the  ordinary  candle  wicking  that  has  been  employed  in 
the  past  by  some  operators  in  packing  cavities,  particularly  the  uterus. 
Candle  wicking  was  objectionable  because  it  possessed  no  absorbent  quali- 
ties ;  its  strands  were  so  small  in  diameter  as  to  require  considerable  time  to 
introduce  a  sufficient  quantity  and  it  was  somewhat  too  firm  in  texture. 

The  preparation  here  referred  to  is  a  loosely  twisted,  neatly  rolled, 
unspun  roving  as  taken  from  the  carding  machines.  It  possesses  all  the 
qualities  of  absorbent  cotton,  and  is  prepared  in  the  same  manner  with  the 
exception  that  it  is  in  the  form  of  a  long  slender  roll,  instead  of  being  in 
layers.  It  may  be  sterilized  the  same  as  absorbent  cotton  or  medicated 
with  any  antiseptic.  It  may  be  procured  in  %  and  i  pound  packages. 

Lint  is  of  two  varieties,  now  known  in  the  market  as  lint  and  lint  cloth. 
Originally  the  former  was  used  exclusively.  It  consists  of  a  soft  fluffy  fiber, 
produced  by  scraping  old  linen  cloth  with  the  edge  of  a  sharp  knife  until  a 
loose  raveled  mass  resulted.  As  the  cloth  before  being  scraped  was 
thoroughly  washed  and  boiled,  it  furnished  in  pre-aseptic  days  a  comparative 
sterile  dressing.  It  was  for  this  reason  preferable  to  most  other  forms  of 
material  employed  for  this  purpose,  and  to  its  thorough  cleanliness  is 
probably  due  the  fact  that  no  wound  was  considered  properly  dressed  with- 
out it. 

Lint  Cloth  is  manufactured  from  a  specially  woven  cotton  material  in 
which  large  loosely  twisted  threads  form  the  warp  of  the  material',  while 
the  cross  threads  or  filling  are  fine  and  tightly  twisted.  After  being 
sterilized  in  a  manner  similar  to  aseptic  gauze,  it  is  passed  through  a  lint- 
scraping  machine  in  which  a  knife  is  so  adjusted  that  its  sharp  edge  is 
scraped  or  drawn  across  the  larger  and  more  loosely  woven  threads  in  such 
a  manner  as  to  loosen  and  tear  up  the  fibers,  producing  a  soft  fluffy  surface 
resembling  in  appearance  ordinary  canton  flannel.  It  has  great  absorbing 
capacity  and  is  used  as  a  base  upon  which  to  spread  ointments  or  similar 
applications  in  the  dressing  of  wounds  and  injuries.  One  side  is  soft  and 
downy,  while  the  other  is  hard  and  somewhat  firm;  either  side  may  be 
placed  next  to  the  wound,  the  plain  or  smooth  surface  being  less  apt  to 
adhere.  The  raveled  or  soft  side  is  a  better  absorbent.  It  may  be  covered 
with  rubber  tissue,  oiled  silk  or  similar  substances.  As  found  in  the  market, 
it  may  be  purchased  in  i,  4,  and  16  ounce  packages. 


DRESSINGS.  359 

Paper  Lint  is  manufactured  from  wood  pulp ;  it  has  fair  absorbing  power 
for  fluids  and  may  be  used  as  a  substitute  for  the  poorer  qualities  of  lint. 
Its  main  advantage  is  its  cheapness.  It  may  be  purchased  in  packages  of 
i  pound  each. 

Absorbent  Wool  is  ordinary  wool  prepared  much  in  the  same  manner  as 
absorbent  cotton,  with  the  exception  that  it  is  not  boiled  nor  is  it  necessary 
to  pass  it  through  as  many  breakers  or  picking  machines  as  are  used  in  the 
preparation  of  the  latter.  After  being  thoroughly  washed  and  dried,  it  is 
carded  into  sheets  or  made  into  large  rope-like  rovings  in  which  shape  it  is 
frequently  called  lamb's  wool.  Either  of  these  preparations  may  be  pur- 
chased in  4  or  1 6  ounce  packages. 

Wood  Wool  is  manufactured  by  grinding  ordinary  pine  wood  into  a  fluffy 
mass  and  subjecting  it  to  the  action  of  chemicals  that  extract  or  neutralize 
its  oils,  resins,  etc.  It  may  be  impregnated  with  an  antiseptic.  It  forms  a 
soft  elastic  fibrous  dressing  of  good  absorptive  powers. 

Moose  Pappe  (Hagedorn)  is  a  vegetable  product,  gathered  and  prepared 
in  Germany  and  is  endowed  with  absorbent  qualities  superior  to  gauze, 
absorbent  cotton  or  similar  substances.  It  is  aseptic,  of  a  soft  pliable 
nature,  easily  applied  and  sold  at  a  low  price.  Experiments  have  shown 
that  its  absorbing  qualities  are  more  than  twice  as  great  (by  weight)  as 
absorbent  cotton  and  more  than  one  and  one-half  times  that  of  wood  wool. 

Campbell  has  shown  in  an  exhaustive  article  read  before  the  Manchester 
Medical  Society,  December  2,  1891,  that  moose  pappe  will  absorb  to  20  times 
its  own  weight  of  water.  It  possesses  another  advantage,  in  that  it  can  be 
applied  dry,  moist  or  wet.  Unlike  cotton,  during  or  after  its  saturation  by 
absorption,  the  secreted  fluids  are  not  held  between  the  fibers  or  externally, 
as  in  a  sponge,  but  they  are  actually  shut  up  or  enclosed  within  the  capillary 
cells  of  the  mass. 

This  quality  renders  the  material  particularly  adapted  as  an  absorbent 
in  all  suppurative  cases,  such  as  abscesses,  ulcers,  etc.  It  is  a  wonderful 
deodorizer  and  should  be  given  a  trial  in  all  cases  where  foul  smelling 
excretions  are  being  discharged. 

After  gathering  it  is  picked  over,  washed,  dried  and  pressed  into  sheets 
or  sewed  into  balls  with  a  gauze  covering.  As  found  in  the  market,  it 
resembles  an  herb  that  has  been  gathered  "stalks  and  leaves."  It  is 
usually  pressed  into  sheets  while  moist  and  is  of  two  qualities,  one  the 
ordinary  moose  pappe,  the  other  a  finely  prepared  quality  used  in  making 
compresses.  The  former  is  sold  by  the  pound,  the  latter  by' the  sheet,  the 
size  being  24  by  32  millimeters. 

Spongiopiline  is  a  light,  soft  fabric  composed  of  sponge  and  muslin, 
and  possesses  great  powers  of  absorption.  It  is  manufactured  in  sheets  of 
from  %  to  ^  inches  in  thickness,  and  covered  with  a  glazing  of  india 
rubber  or  other  water-proof  material,  that  it  may  the  better  retain  moisture 
by  preventing  evaporation.  It  may  be  obtained  in  sheets  of  any  desired 
size. 

Paddings  and  Compresses. 

These  consist  of  soft,  spongy  elastic  materials,  such  as  are  suitable  to 
pad,  protect  or  compress  injured,  diseased  or  other  surfaces.  The  sub- 
stances usually  employed  for  this  purpose  are  cotton,  oakum,  jute  and  wood 
wool. 

Cotton  is  the  ordinary  sheet  cotton  of  the  market,  found  either  in  the 
shape  of  cotton  batting  or  in  especially  prepared  layers  adapted  for  surgical 


360  MINOR    OPERATIVE    SURGERY. 

use.  Ordinary  wadding  is  in  sheets  of  about  y2  inch  in  thickness  and  may 
be  purchased  from  the  dry-goods  stores.  One  side  is  covered  with  a  paste 
substance  that  holds  the  fibers  together.  It  is  better  if  the  surgeon  peel 
off  this  paste  surface  before  application. 

Plain  surgical  cotton  is  prepared  similarly  to  absorbent  cotton,  excepting 
that  it  does  not  pass  through  the  boiling  and  sterilizing  process,  nor  is  it 
closely  carded.  As  cotton  in  this  form  is  not  suitable  for  application  over 
an  open  wound,  its  use  should  be  confined  to  unbroken  skin  surfaces,  such  as 
simple  fractures,  etc.  Its  principal  advantage  is  as  a  material  for  padding 
splints  and  relieving  portions  of  the  body  from  undue  pressure  either  in 
the  application  of  splints  or  bandages,  or  as  pads  in  cases  of  bed  sores  and 
similar  ailments. 

Oakum  or  Marine  Lint  is  manufactured  from  old  tarred  rope  by  untwisting 
it  into  a  loose  fibrous  mass.  Being  elastic  it  is  well  adapted  for  padding 
splints,  deformity  apparatus,  etc.  It  is  also  used  for  pads  to  place  under 
patients  to  relieve  portions  of  the  body  from  pressure,  or  to  absorb  dis- 
charges that  may  soak  through  the  dressings.  It  is  too  irritating  to  place 
in  direct  contact  with  the  skin.  It  may  be  rendered  antiseptic  by  steam 
sterilization,  after  which  it  may,  if  desired,  be  medicated  similar  to  gauze 
and  absorbent  cotton.  It  may  be  purchased  in  any  quantity,  though  a 
lower  price  can  be  obtained  in  original  packages  of  fifty  pounds  each. 

Jute  is  manufactured  from  the  fiber  of  the  corchorus  capsularis,  grown 
chiefly  in  Bengal.  It  may  be  sterilized  by  boiling  or  steaming,  after  which 
it  may  be  medicated  as  desired.  Some  surgeons  prefer  to  use  it  after  it 
has  been  bleached,  and  for  their  use  it  is  passed  through  a  bleaching  process 
similar  to  that  employed  for  absorbent  cotton.  It  may  be  purchased  in 
bulk  or  in  packages  of  one  pound  each. 

A  preparation  of  tarred  jute  is  in  use  by  some  hospitals.  In  its  manu- 
facture a  small  quantity  of  ordinary  pine  tar  is  incorporated  with  or  spread 
upon  the  fiber. 

Protectives. 

Protectives  are  employed  as  wound  coverings,  either  to  shield  parts  from 
external  infection  or  to  prevent  the  escape  of  moisture  or  fluids  contained 
in  dressings.  The  substances  in  common  use  are  oiled  silk,  oiled  muslin, 
Lister's  protective,  gutta  percha  tissue,  rubber  dam,  waxed  or  paraffin 
paper  and  mackintosh  or  jacconette. 

Oiled  Silk  consists  of  fine  silk,  spread  or  coated  with  an  elastic  water- 
proof material.  It  is  manufactured  from  fine  French  silk  grenadine  by 
passing  it  through  a  linseed  oil  varnish,  and  after  drying  subjecting  it  to  a 
coat  of  fine  copal  varnish.  Usually  it  is  semi-transparent,  though  an 
opaque  variety  is  sometimes  employed.  The  latter  is  manufactured  by 
applying  powdered  soap  stone  as  a  final  coat.  It  is  employed  as  a  covering 
for  dressings,  for  which  purpose  it  forms  an  agreeable  and  non-irritating 
material.  It  is  an  ideal  substance,  its  only  objection  being  its  high  price. 
It  may  be  obtained  in  packages  36  inches  in  width  and  either  one  or  five 
yards  in  length. 

Oiled  Muslin.  In  the  preparation  of  this  article  a  fine  closely  woven 
glazed  material  similar  to  tracing  cloth  is  employed,  its  preparation  being- 
identical  with  that  of  the  oiled  silk  before  described.  Its  cheapness  is  its 
only  advantage.  For  some  purposes  it  has  the  disadvantages  of  being  thicker 
and  heavier,  and  consequently  less  pliable. 

Lister's  Protective,  as  devised  by  Lister,   consists  of  a  special  prepara- 


PROTECTIVES BANDAGES.  361 

tion  of  green  oiled  silk  and  is  manufactured  by  rubbing  over  the  surface  of 
the  silk  a  mixture  of  i  part  of  dextrine,  2  parts  of  powdered  starch,  and  16 
parts  of  a  5  per  cent,  solution  of  carbolic  acid.  This  forms  a  part  of  the 
once  famous  Lister  carbolic  gauze  dressing.  It  is  non-irritating  and 
impermeable  to  fluids  and  carbolic  acid,  and  is  used  not  only  as  a  general 
protective,  but  to  guard  the  edges  of  wounds  from  the  direct  action  of 
carbolic  acid.  It  may  be  purchased  in  pieces  one  yard  square. 

Gutta  Percha  Tissue  consists  of  a  thin  tissue-like  sheet  of  gutta  percha. 
It  possesses  a  smooth,  glossy  surface  and,  while  soft  and  pliable,  has 
sufficient  strength  to  be  utilized  for  dressing  purposes.  It  offers  a  cheap 
and  quite  satisfactory  substitute  for  oiled  silk  and  muslin.  It  may  be  used 
as  a  covering  for  dry  dressings  to  prevent  outside  infection,  or  for  moist 
dressings  to  prevent  evaporation.  It  should  not  be  brought  into  contact 
with  broken  skin  surfaces  as  it  is  difficult  to  sterilize.  It  must  not  be 
placed  in  hot  solutions  as  they  soften  its  fiber.  It  may  be  purchased  in 
pieces  i,  5  or  100  yards,  36  inches  in  width. 

Rubber  Dam  is  a  fine,  pure  india  rubber  tissue.  It  is  manufactured 
from  pure  gum  and  differs  from  the  material  of  an  ordinary  rubber  bandage 
only  in  being  thinner.  In  addition  to  its  pliability  and  elasticity,  it  is 
readity  cleaned  and  sterilized  either  by  soap  and  water,  carbolic  acid, 
steaming  or  immersion  in  boiling  water.  It  is  employed  for  purposes 
similar  to  oiled  silk,  gutta  percha  tissue,  etc. 

Waxed  Paraffin  .Paper  is  prepared  by  passing  a  strong  parchment- 
like  sheet  of  tissue  paper  through  melted  wax  of  paraffin.  After  being 
dried  it  forms  a  cheap  substitute  for  oiled  silk  and  muslin.  It  is  es- 
pecially adapted  for  emergency  work  because  of  the  compactness  with 
which  it  may  be  rolled.  Its  usual  width  is  20  inches  and  the  length  of  rolls 
ten  yards. 

Mackintosh  or  Jacconette  consists  of  a  thin,  firm  cotton  cloth  having  upon  > 
one  side  a  layer  of  india  rubber.  It  is  soft  and  pliable  and  is  used  as  an 
outside  layer  in  the  application  of  antiseptic  dressings.  It  shoiild  be 
applied  with  the  rubber  surface  next  to  the  wound.  It  prevents  the 
entrance  of  air  and  forms  a  barrier  to  the  discharge  of  serum  from  the 
dressings  to  the  padding,  bandages,  splints,  etc. 

Bandages. 

These  usually  consist  of  strips,  triangles  or  squares  of  muslin  or 
other  material  employed  in  surgery  for  the  proper  retention  of  dressings, 
splints,  etc.,  and  for  the  compression,  protection  or  support  of  diseased 
or  injured  parts.  They  may  be  classified  as  inelastic,  semi-elastic  and 
elastic.  A  fourth  class  of  bandages,  those  filled  with  hardening  ma- 
terial, such  as  plaster  of  paris,  etc.,  will  be  described  later  under  the  head 
of  splints. 

Inelastic  Bandages  are  usually  employed  because  they  are  more  useful 
and  less  expensive  than  other  varieties.  They  are  generally  known  as 
ribbon  or  roller  and  triangular. 

These  Ribbon  or  Roller  Bandages  are  of  varying  widths  and  lengths 
and  should  be  composed  of  a  single  piece  of  cloth  free  from  seams,  selvage 
or  uneven  surfaces,  and  that  they  may  be  readily  applied,  they  are  usually 
rolled  into  firm  even  cylinders  in  which  form  they  are  known  as  roller 
bandages.  The  surgeon  may  procure  his  supply  rolled  ready  for  use,  or  he 
can  purchase  the  necessary  material  and  manufacture  them.  If  the  latter 
plan  is  followed,  the  bandages  may  be  rolled  by  hand  or  with  a  suitable 


362 


MINOR    OPERATIVE    SURGERY. 


machine  or  bandage  roller.     They  are  best  when  torn  and  with  the  selvage 
edge  removed. 

Roller  bandages  both  in  width  and  length  of  strip  vary  according  to  the 
size  of  patient  and  the  part  to  which  they  are  to  be  applied.  Those  most 
commonly  used  are : 

Width. 

iy2  to  2^ 

3      to  4 


inches 


Length. 

8  to  12  vards 

6 

8 

I 

2 

4 

5 

3 

5 

5 
6 

7 
10 

2 

3 

8 

12 

6 

9 

i 

2 

8 

12 

For  the  arm, 
chest, 
finger, 

foot,        2  y2 

hand,  i 

head,          2     to  2- 

leg,  2^ 

penis,  Y^. 

shoulder,   2  y2 

thigh,         3 

toes,  y± 

trunk,        3     to  4 

While  bandages,  as  usually  procured  in  the  market,  are  rolled  and  ready 
for  application,  every  practitioner  of  medicine  should  receive  the  requisite 
instruction  to  enable  him  to  properly  prepare  a  roller  bandage. 

It  is  usually  necessary  in  the  progress  of  a  case  in  which  bandages  are 
employed  to  remove  and  reapply  them,  and  as  the  standing  of  the  surgeon 
is  frequently  gauged  by  his  mechanical  ability,  it  is  to  his  interest  to  give 
evidence  to  his  patrons  of  his  training  and  skill  in  this  particular  direction. 
Bandage  Rollers  may  be  procured  in  a  variety  of  forms,  varying  from  the 
miniature  pattern  of  Jackson,  figure  796,  to  the  large  apparatus  shown  by 
figure  798. 

Jackson's  Bandage  Roller,  as  sketched  in  figure  796,  is  probably  the 
smallest  instrument  of  its  class.  It  is  only  5  inches  in  extreme  length  and 


Figure  796.    Jackson's  Bandage  Roller. 

weighs  less  than  2  ounces.  Its  advantages  consist  in  its  compactness  and 
simplicity.  It  is  particularly  adapted  for  carrying  in  an  emergency  bag. 
It  will  be  found  useful  for  rolling  new  bandages  and  for  re-rolling  those 
removed  from  patients.  With  it  a  bandage  of  ordinary  length  and  of 
any  width  not  to  exceed  three  inches,  may  be  rolled  tightly  and  smoothly 
with  even  ends.  The  shaft  is  so  constructed  that  it  may  easily  be  de- 
tached from  the  bandage.  With  only  a  limited  amount  of  practice  in  using 
this  small  apparatus,  bandages  can  be  rolled  easily  and  with  considerable 
rapidity. 

The  Plain  Bandage  Roller,  shown  in  figure  797,  is  one  of    the  oldest 
patterns  still  in  common  use.     It  consists  of  a    solid  metal   framework 


BANDAGE    ROLLERS. 


363 


supporting  a  triangular  shaft,  the  latter  terminating  in  a  crank.  The 
shaft  is  held  in  place  by  a  spring  of  peculiar  shape  which  fits  into  a  groove 
formed  in  a  collar  upon  the  shaft  just  outside  of  one  end  of  the  metal 
frame.  The  whole  is  mounted  upon  a  wood  base  and  furnishes  an  appa- 


Figure797.    Plain  Bandage  Roller. 

ratus  firm,  solid  and  neat  in  appearance.       The  height  of  the  apparatus  is 
4*^,  while  the  base  is  4^  by  7  inches. 

Jobse's  Bandage  Roller,  as  it  appears  in  figure  798,  consists  of  a  square 
shaft ,  supplied  with  a  crank  and  mounted  in  the  center  of  two  discs,  one  of 
which  slides  on  the  shaft,  so  that  it  may  be  adjusted  to  any  desired  width  of 


Figure  798.    Jobse's  Bandage  Roller. 

bandage.  The  disc  nearest  to  the  handle  has  a  suitable  frame  work  and 
clamp  by  which  the  apparatus  may  be  firmly  attached  to  a  table,  board  or 
other  fixed  support.  Three  lateral  bars,  each  about  y%  inch  square  and  TV 
inch  apart,  are  arranged  for  imparting  friction  to  the  passing  bandage  that 
it  may  be  wound  tightly  upon  the  shaft.  The  latter  is  removable,  so  that 
after  a  bandage  has  been  rolled,  the  shaft  may  be  withdrawn  and  the 


364 


MINOR    OPERATIVE    SURGERY. 


bandage  removed.  The  whole  forms  a  strong,  convenient  and  efficient 
apparatus,  of  good  appearance  and  inexpensive. 

The  fabrics  more  commonly  used  for  roller  bandages  are  muslin 
unbleached,  muslin  bleached,  muslin  rendered  adhesive,  gauze  and  crino- 
line. 

Unbleached  Muslin  Bandages.  Because  of  their  softness  and  lower 
price  these  are  more  extensively  employed  than  any  other  form.  They  can 
be  purchased  in  boxes  containing  one  pound  each  of  assorted  sizes,  or  they 
may  be  procured  by  the  dozen  of  any  desired  width  and  length. 

Bleached  Muslin  Bandages  are  usually  manufactured  from  extra  qualities 
of  muslin  that  have  not  only  been  bleached  and  freed  from  impurities,  but 
washed  and  ironed.  Such  bandages  should  be  soft,  clean  and  nearly  white. 
They  can  be  purchased  by  the  pound,  assorted,  the  same  as  unbleached 
bandages,  or  they  may  be  procured  in  sizes  as  wanted. 

Adhesive  Bandages  in  some  respects  resemble  a  plaster,  as  they  possess 
adhesive  qualities,  inasmuch  as  they  will  adhere  to  themselves.  A  single 
turn  around  a  limb  will  remain  in  place,  provided  the  ends  are  allowed  to 
overlap  and  one  be  placed  on  top  of  the  other  and  the  two  firmly  pressed 


Figure  799.    Triangular  Bandage. 


together.  They  will  not  stick  to  the  skin  or  other  tissues  and  for  this 
reason  may  by  used  to  great  advantage  in  supporting  dressings,  compresses, 
paddings,  splints,  etc.  In  their  preparation  the  plaster  mass  is  spread  upon 
strong  linen  cloth  of  a  very  pliable  nature.  As  the  adhesive  material  is 
spread  upon  both  sides,  it  is  as  readily  reversed  as  the  ordinary  roller  band- 
age and  is  thus  adapted  to  uneven  surfaces,  in  cases  where  an  adhesive 
plaster  could  be  applied  only  with  difficulty.  It  is  water-proof,  another 
feature  that  recommends  it  highly  for  surgical  purposes,  as  it  may  be 
utilized  where  either  hot  or  cold  water  applications  are  employed.  It  may 
be  purchased  in  rolls  often  yards  each,  either  ^,  i,  i^  or  2  inches  in 
width. 

Gauze  Bandages  should  be  manufactured  from  the  finer  grades  of 
antiseptic  gauze.  They  may  be  procured  assorted  in  one  pound  boxes,  or 
in  quantities  as  wanted,  of  any  desired  size. 

Crinoline  Bandages,  like  the  varieties  formerly  described,  may  be  pur- 
chased in  assorted  packages  of  one  pound  each,  or  in  quantities  to  suit 
almost  any  size. 

Triangular  Bandages  are  made  by  cutting  a  square  of  cloth  diagonally 
from  corner  to  corner,  forming  two  right-angled  triangles  of  equal  size  and 


BANDAGES. 


365 


shape.     They    are    particularly    adapted    for   military,   police   and   other 
emergency  use. 

Though  first  designed  by  Mayor,  they  usually  bear  the  name  of  Esmarch, 
because  he  gave  them  prominence  by  their  introduction  into  the  German 
army.  The  pattern  known  as  Esmarch 's  is  printed  with  illustrations  show- 
ing some  of  the  many  ways  in  which  these  bandages  may  be  applied. 
Similar  designs  bear  the  name  of  the  St.  John's  Ambulance  Association  of 
England,  and  the  St.  Andrew's  Ambulance  Association  of  Scotland.  Any 
of  these  may  be  cut  or  folded  in  various  sizes  and  forms  as  desired.  If 
bandages  one-half  the  regular  size  be  desired,  they  may  be  folded  and  cut 
in  half.  Cravat  bandages  of  any  desired  width  may  be  folded,  and  these 
when  necessary  may  be  twisted  into  tourniquets.  They  may  also  be  used  as 
slings,  temporary  dressings,  coverings  for  the  head,  etc.  As  they  are  less 
dangerous  than  roller  bandages  when  applied  by  inexperienced  hands,  they 
are  much  employed  in  First  Aid  and  emergency  packages. 

Figure  799  exhibits  one  of  the  ordinary  forms.  Usually  they  are  cut 
from  a  square  yard  of  muslin  and  are  generally  sold  in  pairs. 

Semi-Elastic  Bandages  are  made  from  flannel,  silk  netting  or  other  loosely 
woven  material.  They  admit  of  a  certain  amount  of  swelling  of  the  parts 
without  producing  undue  pressure,  and  they  may  be  applied  in  most  cases 
without  "reversing." 

Flannel  Bandages  possess  an  elasticity  not  common  to  any  other  variety. 
For  this  reason  they  are  frequently  employed  as  a  primary  dressing  over 
which  to  place  a  splint  or  plaster  of  paris  dressing,  and  as  a  primary  dress- 
ing following  operations  on  the  eye.  They  also  aid  in  retaining  the  body 
heat.  Only  the  finer  and  softer  grades  of  all-wool  flannel  should  be 
employed  for  bandages,  and  this  in  all  cases  should  have  been  previously 
shrunken.  They  may  be  obtained  in  various  sizes  as  wanted. 

Elastic  Bandages  are  composed  largely  of  rubber,  either  in  the  form  of 
webbing  or  pure  gum,  the  latter  being  usually  preferred.  They  are  em- 
ployed to  secure  elastic  compression  or  circular  constriction  of  limbs,  to 
relieve  hemorrhage,  and  in  a  more  gentle  manner  to  reduce  the  engorge- 
ment of  enlarged  veins,  the  inflammation  around  ulcers,  etc. 


Figure  800.     Rubber  Bandages. 


Figure  801.     Elastic  Web  Bandage. 


Rubber  Bandages,  as  shown  by  figure  800,  may  be  procured  of  varying 
thickness,  width  and  length.  They  are  sometimes  constructed  with  tapes 
securely  fastened  to  one  end  of  the  bandage  to  secure  it  in  place. 

Figure  80 1  shows  an  elastic  web  bandage.  These  are  woven  similar  to 
ordinary  rubber  tape,  the  contractile  power  being  narrow  strips  of  pure 
india  rubber.  They  possess  the  advantages  of  furnishing  support  for 
weakened  parts  and  of  adapting  themselves  to  various  body  movements. 
They  are  employed  in  the  treatment  of  varicose  veins,  ulcers,  etc. ,  for  the 


366 


MINOR    OPERATIVE    SURGERY. 


reduction  of  corpulency  or  support  in  sprains,  dislocations,  etc.     They  may 
be  obtained  in  various  lengths  and  in  widths  of  from  2  to  3  inches. 

Safety  Pins. 

These  are  required  for  properly  securing  bandages,  dressings,  pads,  etc. , 
and  various  sizes  should  be  in  readiness  for  use.  While  the  ordinary 
domestic  pattern  is  more  commonly  employed,  it  presents  disadvantages 
when  applied  to  surgical  use.  Even  with  hands  perfectly  dry  and  free 
from  lubricants,  it  is  often  difficult  to  secure  a  firm  grasp.  When  in  the 


Figure  802.    Cousins'  Surgical  Safety  Pin. 


Figure  803.     Clinton  Safety  Pin. 


grip  of  the  thumb  and  finger,  so  little  surface  is  contacted  that  it  can  not  be 
directed  with  much  precision.  This  faulty  construction  in  many  cases 
requires  more  time  for  manipulation  than  should  be  given  to  this  purpose. 

Cousins'  Safety  Pin,  as  shown  by  figure  802,  differs  from  the  ordinary 
patterns  in  being  constructed  with  a  ring  handle  projecting  from  its  upper 
surface.  This  extension  is  of  sufficient  size  and  thickness  to  enable  the 
operator  not  only  to  quickly  grasp  the  pin,  either  for  the  purpose  of  fasten- 
ing or  unfastening,  but  to  obtain  such  control  that  it  may  be  accurately 
directed ;  in  fact,  with  a  little  practice  it  may  be  manipulated  with  one  hand 
as  easily  as  the  ordinary  pattern  can  with  both.  It  is  manufactured  in 
three  sizes. 

The  Clinton  Safety  Pin  differs  from  the  ordinary  domestic  patterns  in 
being  provided  with  a  projecting  flange,  as  shown  by  figure  803.  The  latter 
furnishes  sufficient  surface  to  afford  a  firm  grip,  an  advantage  that  will  be 
appreciated  by  those  obliged  not  only  to  quickly  loosen  or  apply  bandages, 
but  many  times  to  do  this  with  fingers  wet  with  blood  or  other  liquids. 
They  are  of  strong  construction  and  may  be  obtained  in  various  sizes. 


CHAPTER  XVIII. 


BONE  AND  JOINT  SURGERY. 

While  from  a  pathological  or  surgical  standpoint  it  is  possible  to  classify 
the  various  operations  on  the  bones  and  joints,  it  has  not  been  found  feas- 
ible from  our  position  to  include  lists  of  the  articles  required  for  each  pro- 
cedure. Many  bone  instruments  such  as  scoops,  gouges,  forceps,  etc.,  are 
required  in  nearly  all  operations  where  bone  is  involved.  As  a  result,  if 
lists  of  instruments  were  furnished  for  each  operation,  they  would  be  so 
nearly  alike  as  to  form  a  useless  repetition.  All  will,  therefore,  be  included 
under  the  general  head.  The  several  operations  require  at  least  a  portion 
of  the  following  bone  and  joint  instruments: 

Minor  operating  lists  on  pages  270  to  275. 

Scoops  for  removal  of  diseased  tissue. 

Chisels  for  removal  of  bone  tissue. 

Gouges  for  cutting  away  bone  tissue. 

Osteotomes  for  bone  incisions. 

Mallet  for  driving  chisels,  gouges,  etc. 

Knives,  heavy,  for  resections,  etc. 

Saws  for  bone  incisions. 

Periosteal  elevator  for  separation  of  periosteum. 

Cutting  forceps  for  removing  spiculae,  excising  small  bones,  etc. 

Gouging  forceps  for  removal  of  diseased  bone. 

Forceps  for  holding  bones  during  operations. 

Sequestrum  forceps  for  removing  sequestra,  spiculae,   splinters,  etc. 

Hook  for  holding  or  removing  sequestra. 

Drills  for  perforating  bone. 

Surgical  motor  or  engine. 

Trephine  for  removing  small  pieces  of  bone. 

Trephine  marker  for  marking  point  for  trephine  center  before  removal 
of  soft  tissues. 

Trephine,  brush  for  cleaning  bone  dust  from  trephine  track. 

Skiill  saw  for  making  or  enlarging  opening. 

Elevator  for  raising  splintered  sections  of  bone. 

Bone  chips  for  filling  osseous  cavities. 

Nails  for  joining  bones  after  excisions,  fractures,  etc.,  and 

Extension  apparatus  to  guard  against  contraction. 

Bone  Scoops. 

These  consist  of  strong,  sharp-edged,  spoon-shaped  instruments  used  for 
separating  or  removing  necrosed  bone  or  the  contents  of  suppurative  tracts. 
As  bone  spoons,  curettes,  etc.,  refer  to  instruments  for  the  same  pur- 
pose, we  will  include  all  under  this  head  in  order  to  avoid  confusion. 

367 


368 


BONE    AND    JOINT    SURGERY. 


As  scoops  can  be  more  accurately  employed  than  other  gouging  instru- 
ments, they  are  less  liable  to  injure  surrounding  structures.  For  this  reason 
they  are  generally  considered  safer  and  given  preference.  If  the  surgeon 
is  provided  with  various  sizes  and  forms,  no  other  instrument  of  this  class 


Figure  804.    Volkmann's  Scoop. 

will  be  necessary  in  many  cases.  They  should  be  carefully  constructed 
with  stiff,  strong  shanks  and  handles,  accurately  ground  and  with  smooth 
even  edges. 

Scoops,  gouges  and  chisels  may  be  found  in  the  market  in  various  sizes 
of  each  pattern.     The  number  of  sizes  of  any  one  model  may  differ  when 


Figure  805.     Schede's  Scoop. 

compared  with  some  other  pattern,  and  the  numbers  by  which  each  are 
known  vary  with  different  makers.  That  a  standard  may  be  adopted  we 
suggest  that  instruments  of  this  class  be  known  by  the  number  of  sixteenths 
of  an  inch  represented  by  the  breadth  or  diameter  of  each.  Thus  a  No.  3 
scoop  or  chisel  would  be  •£•$•  of  an  inch  broad,  a  No.  5,  T5?,  etc.  The  dif- 
ference between  these  sizes  seems  ample  for  grading  purposes,  and  by  the 


Figure  806.    Von  Bruns'  Scoop. 

adoption  of  this  system,  dealers  and  surgeons  would  be  able  to  understand 
each  other  in  the  transmission  of  orders. 

Volkmann's  Scoop,  as  outlined  in  figure  804,  is  widely  recommended  by 
operators  and  is  one  of  the  most  useful  instruments  of  its  class  It  consists 
of  a  sharp-edged  oval  or  spoon-shaped  scoop,  the  long  diameter  of  the  bowl 
being  about  one  and  one-half  times  that  of  the  short  diameter.  The  mar- 


Figure  807.    Hebra's  Scoop. 


gin  is  sufficiently  sharp  to  be  used  in  cutting  diseased  bone,  while  the  spoon- 
shaped  cavity  may  be  employed  for  the  removal  of  any  necrosed  tissues. 
The  shank  is  of  steel,  terminating  in  a  handle  usually  hollow  and  sufficiently 
large  to  afford  a  firm  grip.  They  can  generally  be  found  in  sizes  of  bowls 


BONE   SCOOPS.  369 

varying  from  four  to  eight  sixteenths  of  an  inch  in  their  short  diameter. 
Their  usual  length  is  7  inches. 


Figure  808.    Treves'  Douche  Scoop. 

Schede's  Scoop,  as  traced  in  figure  805,  differs  from  the  pattern  of  Volk- 
mann  in  being  constructed  with  a  bowl  of  a  more  slender  oval  pattern.  In 
this  instrument  the  long  diameter  is  about  double  that  of  the  short  diameter. 
They  are  finished  with  sharp  cutting  edges,  strong  shanks  and  large  hollow 
handles.  Their  usual  length  is  seven  inches,  while  the  sizes  of  the  bowls 
vary  from  three  to  five  sixteenths  of  an  inch  in  their  short  diameter. 

Von  Brims'  Scoop,  as  illustrated  in  figure  806,  differs  from  Volkmann's 
in  having  a  round  instead  of  an  oval  bowl.  The  usual  sizes  vary  from 
four  to  eight  sixteenths  of  an  inch  in  diameter.  Their  length  is  the  same 
as  Volkmann's. 

Hebra's  Scoop,  as  shown  in  figure  807,  differs  from  Von  Bruns'  in 
having  the  bowl  fenestrated  or  open  through  the  center.  It  is  constructed 
from  one  piece  of  steel  and  is  usually  made  in  three  sizes,  five,  six  and  seven 
sixteenths  of  an  inch  in  diameter  of  bowl.  Their  length  is  about  6^ 
inches. 

Treves'  Douche  Scoop,  as  portrayed  in  figure  808,  is  similar  in  form  to 
Von  Bruns'  but  constructed  with  a  tubular  shank  and  handle,  one  end  of 
the  tube  terminating  in  the  bowl  of  the  scoop,  the  other  ending  in  a  bulb 


Figure  809.    Volkmann's  Double  End  Scoop. 

for  attachment  to  an  irrigator.  It  utilizes  the  flushing  action  of  a  stream 
of  water  in  connection  with  the  scraping  or  cutting  quality  of  the  scoop. 
By  means  of  this  device  loosened  particles  of  tissue  may  be  washed  from  the 
cavity  as  fast  as  separated  or  cut  away  by  the  gouging  action  of  the  instru- 
ment. It  not  only  enables  the  operator  to  .inspect  the  cavity  at  any  time 
during  the  operation,  but  saves  time,  for  when  the  operation  is  completed, 
the  cavity  has  been  thoroughly  washed  out. 

Volkmann's  Double  End  Scoop,  as  illustrated  in  figure  809,  consists  of 
a  slender  shank  terminating  at  each  end  in  an  oval  scoop.  These  differ  in 
form,  one  having  the  long  diameter  about  twice  that  of  the  short  one,  while 
the  other  is  three  times  that  diameter.  Both  edges  are  quite  sharp,  and  as  the 
instrument  furnishes  two  scoops  of  varying  sizes  and  shapes,  it  is  a  desir- 
able pattern. 


Figure  809A.    Senn's  Scoop  and  Periosteal  Elevator. 

Senn's  Scoop  'and  Periosteal  Elevator,  as  set  forth  in  figure  809 A,  is  a 
small  pattern  designed  for  use  in  pocket  cases,  where  space  is  limited.  It 
consists  of  a  central  handle  terminating  at  one  end  in  a  small  gauge,  and 
at  the  other  in  a  delicate  periosteal  elevator  with  convex  outer  edge.  The 
latter  is  of  such  shape  that  it  may  be  used  for  the  separation  of  tissues. 

24 


370 


BONE    AND    JOINT    SURGERY. 


Chisels. 

Chisels  for  surgical  use  do  not  differ  in  general  shape  from  those  em- 
ployed by  carpenters.  They  are  used  for  shaving,  paring  or  cutting 
away  sections  of  bone.  They  should  be  manufactured  from  a  single  piece 
of  steel  and  the  proximal  end  rounded  for  use  with  a  mallet  by  which  they 


Sections  of  Properly  and  Improperly  Shaped  Chisels. 

are  usually  operated.  One  side  of  the  chisel  blade  should  be  straight,  the 
other  forming  a  short  bevel  at  the  cutting  edge,  while  the  lateral  margins 
should  be  parallel.  The  thickness  of  the  blade  at  the  base  of  the  beveled 
portion  should  not  exceed  two  to  three  sixteenths  of  an  inch,  otherwise  it 


Figure  810A.    Plain  Chisel. 

may  tend,  in  deep  sections,  to  splinter  the  bone.  The  temper  should  be 
harder  than  that  in  common  wood-cutting  chisels,  and  softer  than  the  cold 
chisels  used  for  cutting  iron.  Special  chisels  are  therefore  required,  the 
quality  of  which  should  be  tested  on  the  thigh  bone  of  an  ox  before  attempt- 
ing an  operation.  The  edges  should  be  sharp,  so  they  will  not  only  cut  with 
a  minimum  blow,  but  so  that  they  will  not  slip  when  it  is  necessary  to  re- 
move bone  tissues  by  cutting  nearly  or  quite  on  a  line  with  the  shaft.  The 
width  of  the  chisel  selected  should  depend  upon  the  size  of  the  bone  on  which 
the  operation  is  to  be  performed.  The  ordinary  size  is  half  an  inch  in 
width.  The  width  should,  however,  be  less  than  the  diameter  of  the  bone 
to  be  operated  upon,  otherwise  the  adjacent  soft  tissues  may  be  injured. 
The  Plain  Chisel,  sketched  in  figure  8ioA,  represents  the  lightest,  sim- 


Figure  811.    Von  Brians'  Chisel. 


plest  and  consequently  least  expensive  pattern  in  use.  They  may  gener- 
ally be  found  in  three  sizes  or  widths,  fa  ^  and  ^  of  an  inch,  the  length 
being  about  5  inches. 

Von  Bruns'  Chisel,  as  shown  in  figure  811,  is  made  from  solid  steel  and 
is  consequently  heavy.  The  handle  is  octagonal,  sufficiently  large  to  furnish 
a  firm  grip,  a  condition  sought  for  in  a  perfect  instrument.  A  chisel  that 
may  be  grasped  in  the  center  of  the  hand  may  be  more  carefully  steadied 
and  more  accurately  directed  than  one  held  by  the  finger  tips  only. 


Figure  811A.    Macewen's  Chisel. 


To  grasp  an  instrument  of  this  character  in  the  center  of  the  hand  is  to 
bring  it  into  contact  with  a  greater  extent  of  tactile  surface,  thus  quicken- 
ing the  surgeon's  sense  of  touch,  and  enabling  him  to  intelligently  direct  the 
operation  even  in  recesses  too  deep  for  ocular  examination.  This  advan- 
tage has  rendered  this  pattern  of  chisel  popular,  particularly  with  surgeons 


CHISELS — GOUGES. 


371 


with  large  practices.  They  are  usually  manufactured  in  four  sizes,  the 
widths  of  blades  being  ^-,  rsff  T^  and  T7F  of  an  inch,  with  a  length  of  7  inches. 
Macewen's  Chisel,  as  exhibited  in  figure  8nA,  does  not  differ  from  the 
pattern  of  osteotomes  devised  by  the  same  inventor,  which  now  form  the 
standard  instruments  in  their  class.  They  may  be  purchased  in  widths  of 
T\»  f\  an<^  yV  °f  an  mcn- 

Gouges. 

These  are  a  form  of  chisel  with  curved  cutting  edges.  They  are  partic- 
ularly useful  in  removing  narrow  tracts  and  central  parts  of  diseased  bone. 
A  few  patterns  are  constructed  for  service  with  the  hand,  but  the  majority 


Figure  812.    Plain  Gouge. 

require  a  mallet  for  successful  operation.  Those  manufactured  with  other 
than  straight  shanks  and  handles  are  known  as  curved  gouges. 

The  Plain  Gouge,  represented  in  figure  812,  is  the  simplest  and  conse- 
quently least  expensive  form  in  the  market.  The  widths  of  blades  are 
usually  ^,  T8g-  andT7^  of  an  inch,  while  the  length  is  about  5^  inches. 

The  Plain  Curved  Gouge,  displayed  in  figure  813,  is  one  of  the  simplest 
of  the  curved  variety.  Like  the  one  last  described,  its  chief  advantage  con- 


Figure  813.    Plain  Curved  Gouge. 

sists  in  its  low  price.  Its  curved  handle,  however,  admits  of  its  being  used 
by  the  hand  after  the  manner  of  a  scoop.  Its  width  is  usually  fe  of  an 
inch,  and  its  length  7  inches. 

Von  Bruns'  Straight  and  Curved  Gouges,  as  set  forth   in  figures  814  and 
815,  represent  two  desirable  patterns  made  from  solid  steel.   The  employment 


Figure  814.    Von  Bruns'  Straight  Gouge. 


Figure  815.    Von  Bruns'  Curved  Gouge. 

of  these  instruments  by  one  who  has  previously  used  the  more  slender  vari- 
eties, illustrated  by  the  two  figures  last  described,  will,  we  think,  demon- 
strate the  advantages  of  operating  with  gouges  that  are  large  enough  in 
the  diameter  of  their  handles  to  admit  of  their  being  firmly  held  in  the  cen- 
ter of  the  hand.  Their  widths  are  ^,  -fa  and  T\  of  an  inch,  with  a  length  of 
about  7  inches. 

The  Gouge  for  Use  with  the  Hand  or  Mallet,  as  delineated  in  figure  816, 
is  particularly  adapted  to  the  use  of  those  operators  who,  for  any  reason, 
are  likely  to  confine  their  purchases  of  bone  gouges  to  a  single  instrument 


372 


BONE    AND    JOINT    SURGERY. 


Its  weight,  shape  and  construction  are  such  that  it  can  be  advantageously 
used  either  by  hand  or  with  mallet.  They  are  usually  T*^  of  an  inch  wide 
and  about  6  inches  in  length. 

Macewen's  Gouges,  as  represented  in  figure  817,  are  manufactured  from  a 
single  piece  of  steel,  and  are  among  the  heaviest  and  most  expensive  of  this 
class  of  instruments.  As  they  have  large  heads  and  handles,  they  must  be 
forged  from  a  heavy  bar  of  steel,  thus  increasing  the  labor  of  making.  In 


Figure  816.    Gouge  for  Use  with  Hand  or  Mallet. 

order  to  afford  a  firm  grip,  the  handles  are  hexagonal  and  present  the  appear- 
ance of  slightly  decreasing  cones,  terminating  in  smooth,  rounded  shanks, 
in  the  distal  ends  of  which  the  gouges  are  formed.  Owing  to  their  weight  and 
firmness  they  are  the  most  valuable  patterns  found  in  this  class  of  instru- 


Figure  817.    Macewen's  Gouges. 

ments.     They  are  usually  about  7  inches  in  length,  and  of  three   widths 
each,  j^,  T6^  and  T7F  of  an  inch. 

Macewen's  Curved  Gouges,  as  outlined  in  figure  818,  are  patterns  similar 
in  construction  to  those  last  described,  differing  only  in  that  the  gouging 
or  cutting  portions  are  curved  at  an  angle  with  the  handle  axis.  The  shape 


Figure  818.    Macewen's  Curved  Gouges. 


of  this  instrument  is  something  like  that  of  a  bayonet,  and  in  cases  of  exten- 
sive necrosis  in  the  long  diameter  of  bones  can  be  more  advantageously  used 
than  the  straight  pattern.  The  sizes  and  lengths  are  the  same  as  of  the  one 
last  described. 

Szymanowsky's  Gouge,  as  illustrated  in  figure  819,  is  a  short  curved  pat- 
tern, provided  with  a  somewhat  large  and  heavy  handle  intended  for  use  with 


OSTEOTOMES. 


373 


the  hand.  The  cutting  blade  is  sharply  curved  on  the  flat,  the  proximal 
portion  being  serrated  or  roughened  in  order  to  furnish  a  firm  resting-place 
for  the  thumb  of  the  operator.  The  instrument  possesses  the  combined  ad- 


Figure  819.    Szymanowsky's  Gouge. 


vantages  of  a  gouge  and 
length  and  in  two  sizes,  - 


a  scoop.     They  are  usually  about  six  inches  in 
and  ^  of  an  inch  in  breadth. 

Osteotomes. 

These  are  chisels  with  thin  wedge-like  blades,  employed  for  bone  incis- 
ions. They  differ  from  chisels,  as  the  edges  or  faces  are  straight  and 
without  bevel.  For  this  reason  they  are  not  employed  in  the  removal  of 
bone.  One  border  or  lateral  edge  of  the  blade  is  graduated,  usually  in  half 
or  quarter  inches  ;  this  is  employed  to  show  the  depth  of  the  incision.  By 
measuring  the  thickness  of  the  bone  to  be  severed  before  operating,  esti- 
mates may  be  made  so  there  need  be  no  danger  of  injury  to  the  underlying 
soft  tissues.  The  uses  of  this  instrument  require  that  it  be  sharp  enough 
to  pare  a  finger  nail,  and  this  test  is  always  advised  before  using.  The 
temper  should  be  the  same  as  that  of  a  chisel,  not  so  soft  that  the  edge  will 


Figure  820.    Macewen's  Osteotome. 


turn  on  healthy  bone,  nor  brittle  enough  to  "crib"  or  break  off  when 
firmly  embedded  in  solid  tissue.  Great  care  should  be  exercised  in  temper- 
ing the  thinner  portion  of  the  blade,  that  it  may  render  good  service  and 
still  be  safe  from  breakage.  Like  chisels,  they  should  be  tested  on  the  thigh 
bone  of  an  ox  before  use.  In  deep  incisions  there  is  danger  that  the 
instrument  may  become  so  closely  impacted  that  further  progress  will  be  diffi- 
cult, if  not  impossible,  particularly  when  thin  blades  are  employed.  This 
condition  may  be  overcome  by  providing  in  advance,  patterns  with  thicker 
blades,  one  of  which  may  be  substituted  for  the  thin  one  first  employed. 
Three  sizes  are  advised,  y\,  f^-  and  yV  of  an  inch.  If  a  single  one  be  relied 
upon,  it  should  be  of  medium  size. 


Figure  8-21.    Poores'  Osteotomes. 

Macewen's  Osteotomes,  as  pictured  in  figure  820,  seems  to  fill  all  the 
necessary  requirements.  The  handles  are  octagonal,  thus  affording  a  firm 
grip  and  enabling  the  operator  to  note  and  prevent  any  rotary  turning  of 
the  blade.  The  top  of  the  instrument  is  supplied  with  a  deep  groove  sur- 
mounted with  a  rounded  head,  the  whole  forming  an  indentation  for  the 


374 


BONE    AND    JOINT    SURGERY. 


thumb  of  the  surgeon,  a  good  surface  to  receive  the  mallet  blows,  and  fur- 
nishing a  good  grasp  when  it  is  necessary  to  release  the  instrument  from 
the  bone  incision  by  lever  force. 


Figure  822.    Morgan's  Guarded  Osteotome. 

These  patterns,  though  varying  in  size,  should  be  approximately  of  the 
same  weight,  their  inventor  claiming  that  the  hand  educated  to  receive  sen- 
sations produced  by  a  given  weight  ought  not  to  be  misled  by  frequent 
changes  from  one  weight  to  another.  The  sizes  usually  found  in  the  mar- 
ket have  a  width  of  ^-,  T6g-,  -rV  an^  yV  °f  an  mcn>  with  a  length  of  about 
7  inches. 

Poores'  Osteotomes,  as  evidenced  in  figure  821,  differ  from  the  pattern  of 
Macewen  in  having  lighter  blades  and  longer  handles.  The  regular  pat- 
terns are  half  an  inch  in  width  and  differ  only  in  the  thickness  of  the  blades, 
No.  i  being  thin,  No.  2  medium,  and  No.  3  thick.  The  advantages  of  such 
an  assortment  are  described  on  the  preceding  page  A  smaller  size,  known  as 
No.  o  and  much  lighter,  is  only  one- quarter  of  an  inch  in  width.  It  may 
be  employed  for  section  of  the  fibula  or  other  small  bones. 

Morgan's  Guarded  Osteotome,  as  outlined  in  figure  822,  marks  an  appar- 
ent improvement  in  this  class  of  instruments.  In  cutting  the  circumfer- 
ence of  bone  in  an  ordinary  osteotomy,  it  is  often  difficult  to  avoid  injuring 
the  soft  tissues  with  the  outer  edge  of  the  osteotome.  This  can  be  over- 
come by  the  use  of  the  instrument  here  figured.  As  the  guard  is  always  in 
advance  of  the  cutting  edge,  it  can  be  made  to  closely  hug  the  bone,  thus 
avoiding  all  injury  to  blood-vessels,  nerves  and  other  structures.  The  sizes 
are  the  same  as  those  adopted  by  Macewen,  from  whose  instrument  this 
pattern  was  modeled. 

Resection  Knives. 

Special  knives  of  strong  and  heavy  construction  are  preferred  by  some 
operators  for  resection  of  joints  and  such  other  operations  as  involve  dense 


Figure  823.    Frank's  Small  Resection  Scalpel. 


Figure  824.     Frank's  Large  Resection  Scalpel 


Figure  825.    Frank's  Sharp  Point  Resection  Bistoury. 


Figure  826.    Frank's  Probe  Point  Resection  Bistoury. 


or  cartilaginous  tissues.  While  the  larger  sizes  of  scalpels,  as  exhibited  in 
figures  591  to  597,  are  usually  employed  for  this  purpose,  special  knives  in 
bistoury  form  are  in  occasional  demand. 


MALLETS. 


375 


Frank's  Scalpels  and  Bistouries,  as  depicted  in  figures  823  to  826,  differ 
from  the  ordinary  patterns  of  minor  operating  knives  in  that  they  have 
larger  and  much  heavier  blades,  and  handles  large  enough  to  furnish  a 
hand  grasp.  They  are  employed  in  resections  of  the  larger  bones  and  joints 
and  in  operations  on  the  ribs. 

Mallets. 

These  are  a  form  of  hammer  manufactured  from  metal,  wood  or  rawhide. 
The  cutting  force  necessary  in  operating  with  chisels  and  gouges  is  best 
imparted  by  a  mallet  constructed  from  such  material  and  in  such  a  manner 
that  it  will  not  rebound  even  when  a  sharp  blow  on  an  instrument  is  given 
with  it.  Th'e  two  materials  most  often  employed  are  rawhide  and  lead. 

The  Rawhide  Mallet,  pictured  in  figure  827,  is  constructed  from  a  piece 
of  cowhide.  While  in  an  untanned  state,  the  skin  is  rendered  soft  and 
pliable,  is  then  covered  with  glue  and  wound  into  a  small,  tight  roll,  in 
which  position  it  is  secured  by  a  metal  fastener.  A  hole  is  then  bored  in 


the  center  of  the  cylinder  side  into  which  a  wooden  handle  is  driven,  when  it 
is  ready  for  use.  The  usual  dimensions  of  the  head  are  i  ^  inches  in  diam- 
eter and  3  inches  in  length. 


Lead  Mallet. 


The  Lead  Mallet,  shown  in  figure  828,  is  composed  of  a  brass,  lead-filled 
tube,  constricted  in  its  middle,  tapering  from  the  cylinder  ends  to  the  cen- 
ter To  this  head  a  suitable  handle  is  attached.  The  lead  which  forms  the 


Figure  829.    Gerster's  Boxwood  Mallet. 

contact  surface  when  a  blow  is  given,  furnishes  a  soft,  yielding,  inelastic 
mass  with  little,  if  any,  tendency  to  rebound.  The  head  is  usually  about 
2  inches  in  length,  with  a  maximum  diameter  of  about  i  ^  inches. 


376 


BONE    AND    JOINT    SURGERY. 


Gerster's  Boxwood  Mallet,  as  represented  in  figure  829,  is  a  wooden  mallet 
and  handle,  usually  manufactured  from  boxwood.  It  is  claimed  that  with 
this  mallet  there  is  less  tendency  to  rebound  and  that  the  sense  of  touch  is 
more  delicate  than  with  mallets  of  metal. 

Saws. 

For  surgical  use  these  will  not  be  required  in  a  great  variety  of  patterns, 
even  in  an  extensive  practice.  One  capital  and  one  slender  saw,  as  for 
instance  the  author's  bow  saw,  figure  832,  and  the  narrow  Langenbeck's  saw, 
figure  830,  are  really  all  that  are  required  for  ordinary  operations  on  bone. 
They  will  also  answer  for  amputations.  Care  should  be  taken  to  see  that 
the  teeth  are  carefully  cleaned  before  and  after  each  operation.* 

The  proper  manipulation  of  a  surgical  saw,  particularly  in  the  hands  of 
operators  who  have  only  a  limited  surgical  practice,  is  a  matter  that  fre- 
quently receives  too  little  attention.  With  them  the  knife  is  frequently  in 
use,  and  they  become  somewhat  adept  in  its  manipulation.  The  saw,  how- 


Figure  830.    Langenbeck's  Narrow  Saw. 

ever,  since  the  days  of  aseptic  surgery,  but  little  employed,  is  too  often  re- 
garded in  the  light  of  an  ordinary  carpenter's  tool,  unworthy  of  any  special 
attention. 

An  operation  in  which  a  saw  is  to  be  employed  should  not  be  undertaken 
without  an  examination  of  the  instrument,  to  know  that  it  is  in  perfect 
order.  At  the  operating  table,  knives  are  usually  in  duplicate ;  but,  as  a 
rule,  the  surgeon  has  only  one  saw,  and  much,  therefore,  depends  on  its  con- 
dition. It  should  be  sharp,  with  keen  cutting  edges  upon  every  tooth,  and 
should  have  sufficient  "set"  so  that  it  will  not  "bind"  when  passing  through 
a  large  bone. 

After  removal  of  the  periosteum  and  retraction  of  the  soft  parts,  the 
bone  and  limb  should  be  firmly  grasped  on  both  sides  of  the  point  at  which 
it  is  to  be  severed.  The  first  stroke  should  be  made  quickly  and  in  a  back- 


Figure  831.    Lifting- Back  Metacarpal  Saw. 

ward  direction,  the  saw  being  carefully  guided  by  the  fingers  of  the  free 
hand.  The  entire  length  of  the  cutting  edge  should  be  drawn  across  the 
surface  of  the  bone  during  the  stroke,  and  if  carefully  made,  a  groove  will 
be  formed  which  will  serve  as  a  guide  to  the  future  movements  of  the  saw 
blade.  If  the  first  groove  is  not  of  sufficient  depth  for  this  purpose,  a  second 
cut  should  be  made  similar  to  the  first.  The  surgeon  should  avoid  what 
might  be  termed  a  rigid  grasp.  The  saw  handle  should  be  held  somewhat 
loosely  and  operated  quickly  with  a  slight  sweeping  movement.  If  more 
than  one  bone  is  to  be  severed,  both  should  be  cut  at  the  same  time;  that 
is,  the  saw  should  engage  the  surface  of  both  simultaneously,  excepting 
that  the  smaller  bone  should  be  cut  through  first,  that  the  final  strokes  may 


SAWS. 


377 


finish  the  section  of  the  larger  bone.  Care  must  be  exercised  to  see  that  the 
weight  of  the  severed  portion  of  the  limb  is  carefully  and  accurately  sus- 
tained. During  the  operation  of  sawing,  the  parts  should  be  held  in  a  position 
of  accurate  apposition.  If  elevated  too  high,  the  saw  will  "bind"  in  its 
track ;  if  depressed,  the  uncut  portion  is  likely  to  break  and  splinter.  All 
fragments  projecting  from  the  sawed  end  of  a  bone  should  be  removed  with 
cutting  forceps,  while  the  sharp  margin  may  be  rounded  with  the  serrated 
portion  of  an  elevator. 

Langenbeck's  Narrow  Saw,  as  shown  in  figure  830,   is  one  of  the  instru- 
ments necessary  to  every  operating  set,  for  not  only  may  it  be  utilized  in  incis- 


Figure  832.    Author's  Bow  Saw. 


ions,  but  it  may,  in  emergencies,  be  employed  in  osteotomy  and  amputa- 
tions. When  properly  constructed,  the  blade  will  be  thinnest  at  the  back 
that  it  may  not  "pinch"  in  cutting  transversely  through  a  bone,  and  for  the 
further  purpose,  in  osteotomy,  of  sawing  in  a  circular  direction.  The 
cutting  edge  should  be  about  4  inches  with  a  total  length  of  8%  inches. 

The  Lifting-Back  Metacarpal  Saw,  as  illustrated  in  figure  831,  consists 
of  a  thin  saw  blade  attached  to  a  suitable  handle  and  provided  with  a  slot- 
ted lifting-back,  by  which  a  sufficient  amount  of  firmness  or  rigidity  is 
imparted  to  the  blade.  That  the  instrument  may  be  used  in  amputations 
of  the  larger  bones  in  emergencies,  the  back  is  of  the  hinged  or  folding  pat- 


Figure  833.    Grady's  Bow  Saw. 

tern,  that  it  may  rest  out  of  the  way  when  deep  incisions  are  necessary. 
While  the  saws  are  of  various  sizes,  the  blades  are  usually  about  6 
inches  in  length,  the  instrument  having  a  total  length  of  from  9  to  10 
inches. 

The  Author's  Bow  Saw,  as  displayed  in  figure  832,  is  a  modification  of 
a  German  design,  and  is  here  exhibited  as  a  separable  aseptible  instru- 
ment, easily  cleaned.  The  bow  and  handle  are  manufactured  in  one  piece. 
The  blades  are  two  in  number,  one  fine  and  the  other  medium  coarse. 
These  blades  are  thickened  at  their  extremities  until  they  present  on  cross 
section  a  V  shape.  The  slots  in  the  handle  and  lever  that  receive  this  blade 


378 


BONE    AND    JOINT    SURGERY. 


are  wide,  that  they  may  fit  these  thickened  portions,  thus  permitting  the 
cleaning  of  the  slots  with  brush  or  cloth.  The  lever  is  detachable  and  is 
the  power  by  which  the  blades  are  placed  and  maintained  on  a  strain  or  ten- 
sion. The  saw  is  firm  and  rigid,  and  will  meet  all  the  requirements  of  a 
capital  saw  in  any  operation.  The  cutting  surface  is  9^  inches  and  the  total 
length  is  13^  inches. 

Grady's  Bow  Saw,  as  outlined  in  figure  833,  is  a  modification  of  the  last 
described.     Its  claimed  advantages  consist  in  a  shorter  blade,  smaller  frame 


Figure  8*4.     Windler's  Saw. 


and  removable  handle.  It  was  especially  designed  for  use  in  compact  oper- 
ating cases.  Many  cases  of  modern  design  are  constructed  without  long 
amputating  knives.  With  a  saw  of  this  pattern  it  is  possible  to  arrange 
them  in  much  shorter  and  smaller  compass. 

Windler's  Saw,  as  set  forth  in  figure  834,  possesses  the  advantage  of 
being  so  formed  that  its  cutting  edge  may  be  directed  at  various  side  angles, 
so  that  it  has  a  general  application.  It  is  particularly  useful  in  cases  of 
osteotomy.  The  tension  of  the  blade  is  secured  by  the  lever  which  forms 
part  of  the  handle.  The  length  of  the  blade  is  8  inches  and  the  length  of 
the  saw  about  12  inches. 

Parker's  Saw,  as  traced  in  figure  835,  represents  one  of  the  most  popu- 
lar of  the  solid  blade  and  cheaper  patterns.  The  handle  and  stiffening  bar 


Figure  835.     Parker's  Capital  Saw. 

in  the  better  makes  are  constructed  in  one  piece.     The  length  of  its  cutting 
edge  is  about  8^  inches,  while  the  total  length  is  about  12  inches. 

The  Author's  Set  of  Lifting-Back  Saws,  as  clearly  shown  in  figure  836, 
is  somewhat  complicated,  or  at  least  is  composed  of  quite  a  number  of  pieces. 
It  presents  advantages  not  found  in  any  other  solid  blade  or  lifting-back 
pattern.  As  the  parts  are  all  detachable,  it  can  be  thoroughly  cleaned. 
The  handle  can  be  obtained  with  one  or  any  combination  of  blades,  thus 
giving  the  surgeon  two  or  three  saws  at  a  cost  not  largely  in  excess  of  one. 


SAWS. 


379 


The  blades  can  all  be  used  with  or  without  the  lifting-back.  The  latter 
serves  to  stiffen  and  strengthen  the  blade  that  it  may  not  kink  or  double  if 
pressed  upon  partially  severed  bones.  The  sizes  of  blades  and  saws  are  as 
follows : 

Greatest  width  of  blade.  Length  of  cutting  edge.  Total  length  of  saw. 

Small 7/s    inch  Scinches  9^  inches 

Medium 2       inches  8  n 

Large 


Figure  836.    Author's  Set  of  Lifting-Back  Saws. 

The  Skull  Saw  was  for  many  years  the  standard  instrument  employed  for 
cutting  away  wedged  fragments  or  other  portions  of  bone  necessary  to  be 
removed  in  order  to  provide  an  opening  for  the  elevator  or  other  instrument. 
While  still  in  general  use,  many  surgeons  prefer  the  chisel,  gouge  or  goug- 
ing forceps. 

Hey's  Skull  Saw,  as  sketched  in  figure  837,  consists  of  a  double-edged 
saw  blade,  one  side  presenting  a  convex  curve,  the  other  straight,  terminat- 


Figure  837.    Hey's  Skull  Saw. 

ing  at  one  corner  in  a  sharp,  at  the  other  in  a  rounded  point.  This  com- 
bination of  forms  permits  the  use  of  the  instrument  in  a  variety  of  places 
and  positions.  Its  length  is  7  inches,  with  cutting  surfaces  of  about  i  % 
inches  each. 

The  Chain  Saw.  Many  surgeons  now  supplement  the  use  of  this  instru- 
ment by  the  chisel,  gouge,  mallet  and  bow  saw. 

The  Chain  Saw,  set  forth  in  figure  838,  as  its  name  implies,  is  like  a 
chain,  composed  of  numerous  links  or  sections,  each  united  with  strong 
rivets  and  having  a  handle  attached  to  each  extremity.  One  of  the  handles 
is  reversible.  In  placing  the  saw  in  position,  the  handle  is  removed,  after 


380 


BONE    AND    JOINT    SURGERY. 


which  the  saw  is  passed  underneath  the  bone,  either  with  a  large  threaded 
needle  or  by  means  of  the  chain  saw  carrier,  shown  in  figure  839.  The  latter 
is  used  for  passing  a  ligature  or  thread  beneath  the  bone  by  which  the  saw 
is  drawn  into  position.  Its  cutting  length  measures  about  13  inches. 


Figure  838.    Chain  Saw. 

The  Chain  Saw  Carrier,  as  shown  in  figure  839,  is  used  for  carrying  one 
end  of  a  thread  around  the  bone  to  be  cut.  The  length  of  this  instrument 
is  about  9  inches,  while  the  diameter  of  the  curved  needle  is  about 
2  inches. 


Figure  839.    Chain  Saw  Carrier. 

Subcutaneous  Saws  may  be  described  as  narrow,  short  saw  blades,  with 
long  slender  shanks.  They  are  intended  for  cutting  away  portions  of 
longitudinal  bone  sections,  sawing  either  on  straight  or  curved  lines. 

Lente's  Subcutaneous  Saw,  as  illustrated  in  figure  840,  is,  we  believe, 
the  smallest  and  lightest  of  this  class  of  instruments.  It  is  intended  for 
use  only  in  delicate  operations.  The  cutting  surface  of  the  blade  is  but  i  ^ 
inches  in  length,  while  the  length  of  the  entire  instrument  is  6^  inches. 
The  shank  is  as  slender  as  the  nature  of  the  work  will  admit,  while  the 
handle  is  of  some  corrugated  pattern  to  afford  a  firm  grip.  The  blade 
should  be  slender  enough  to  admit  of  its  introduction  into  a  large  drill  hole, 
and  should  be  thin  enough  in  the  back  to  allow  cutting  in  a  circle. 


Figure  840.    Lente's  Subcutaneous  Saw. 

Adams'  Subcutaneous  Saw,  as  outlined  in  figure  841,  is  considerably 
heavier  than  the  pattern  of  Lente  and  is  provided  with  a  handle  which 
furnishes  a  better  grip,  as  it  fills  the  hand  of  the  operator  more  fully. 

Shrady's  Subcutaneous  Saw  and  Trocar,  as  set  forth  in  figure  842,  con- 
sists of  a  flattened  slotted  canula,  provided  with  a  sharp-pointed  trocar  and 


SAWS. 


381 


saw  blade,  both  adjusted  so  as  to  be  operated  within  the  canula.  In  its  con- 
struction a  space  representing  about  one-half  the  lateral  width  of  the 
canula,  commencing  at  a  point  about  three-eighths  of  an  inch  from  the  distal 
end  and  extending  backward  about  2^  inches,  is  cut  away  to  provide  means 
for  the  edge  of  the  saw  to  be  brought  in  contact  with  the  bone  to  be  severed. 
The  trocar  may  be  forced  through  any  overlying  soft  tissues.  Such  tissues 


BS 


Figure  841.    Adams'  Subcutaneous  Saw. 


would  be  protected  from  the  cutting  action  of  the  blade  by  that  portion  of 
the  canula  not  contained  in  the  space  above  referred  to.  After  the  intro- 
duction of  the  trocar  and  canula,  the  former  may  be  removed  and  the  saw 
blade  inserted  in  its  stead.  As  it  is  provided  with  a  separate  handle,  it  may 
be  operated  independent  of  the  trocar. 


Figure  842.    Shrady's  Subcutaneous  Saw  and  Trocar. 


Provision  is  also  made  for  the  withdrawal  of  the  canula,  thus  giving  to 
the  saw  all  the  freedom  of  action  and  adaptability  of  the  Adams  instrument. 
Before  withdrawing  the  saw,  the  canula  should  be  slipped  over  the  blade 
through  the  wound,  thus  avoiding  any  possible  laceration  of  soft  tissues. 

Improvised  Subcutaneous  Saw.  In  the  absence  of  a  special  saw  for 
subcutaneous  operations,  the  surgeon,  if  he  possesses  a  plain  metacarpal 
saw  of  the  Langenbeck  pattern,  figure  830,  may  improvise  one. 


Figure  843.    Improvised  Subcutaneous  Saw. 

The  Improvised  Subcutaneous  Saw,  delineated  in  figure  843,  shows  a 
plain  metacarpal  saw  protected  by  a  piece  of  pure  gum  tubing.  By  this 
method  special  saws  can  be  improvised  that  will,  in  many  cases,  answer  as 
well  as  the  specially  constructed  articles. 

Periosteal  Elevators. 

These  consist  of  strong  blades,  usually  with  edges  smoothed  and  rounded 
that  they  may  not  cut  soft  tissues.  They  are  employed  to  separate  perios- 
teum from  bone.  Under  this  heading  we  will  include  all  instruments  for 
the  elevation  or  removal  of  the  periosteum,  such  as  elevators,  raspatories, 


382 


BONE    AND    JOINT    SURGERY. 


levators,  dry  dissectors  and  periosteotomes.       All  but   the   latter  can  be 
procured  either  with  square,  round,  oval,  concave  or  pointed  edges. 

Sayre's  Periosteal  Elevator,  as  exhibited  in  figure  844,  has  probably  had 
a  more  extended  use  than  any  other  pattern.  It  has  two  blunt  edges,  both 
carefully  rounded,  one  a  slight  oval,  applicable  to  general  work ;  the  other 
pointed,  suitable  for  use  in  depressions,  interosseous  spaces,  etc.  Trans- 


Figure  844.    Sayre's  Periosteal  Elevator. 

verse  corrugations  in  the  center  afford  a  firm  grip.      Its  length  is  about 
7  inches. 

Senn's  Periosteal  Elevator,  as  portrayed  in  figure  845,  is  manufactured 
with  a  chisel-shaped  head,  a  double  concave  handle  and  a  spoon-shaped 
blade.  As  it  has  dull  edges,  it  may  not  only  be  used  as  a  periosteal  elevator, 


Figure  845.    Senn's  Periosteal  Elevator. 


but  as  a  spoon  or  scoop,  either  for  removing  masses  of  carious  bone  or  the 
contents  of  suppurative  tracts  when  of  a  soft  or  spongy  nature.  Its  length 
is  about  f>y2  inches. 

Williams'  Periosteal  Elevator,  as  shown  in  figure  846,  comprises  a  cen- 
tral handle,  each  end  of  which  is  formed  into  an  elevator.     One  end  has  a 


Figure  846.    Williams'  Periosteal  Elevator. 

chisel  shape  with  a  somewhat  narrow  straight  edge,  the  other  is  wide  and 
rounded  with  a  convex  outer  border.     Its  length  is  about  7  inches. 

Bishop's  Periosteal  Elevator,  as  displayed  in  figure  847,  is  a  modification 
of  the  rectangular  pattern  of  Langenbeck.      It  differs  from  the  latter  in 


Figure  847.    Bishop's  Periosteal  Elevator. 


that  the  blades  or  curved  portion  is  bent  at  an  angle  of  70°,  thus  forming 
what  might  be  termed  a  hoe-shaped  instrument.  Its  author  claims  advan- 
tages for  it,  particularly  in  operations  on  the  mastoid,  as  separation  of  the 
periosteum  may  be  accomplished  by  a  drawing  or  pulling  motion.  It  also 
serves  the  purpose  of  a  retractor.  The  usual  width  is  about  8  millimeters. 


Figure  848.    Ferguson's  Periosteal  Elevator  and  Scoop. 

Ferguson's  Periosteal  Elevator  and  Scoop,  as  traced  in  figure  848,  con- 
sists of  a  sharp-edged  elevator  with  a  convex  separating  surface  in  combi- 
nation with  an  oval  sharp  scoop.  The  elevator  may  be  employed  in  remov- 
ing or  breaking  up  sections  of  carious  bone,  as  well  as  separating  the  peri- 
osteal covering.  The  scoop  is  constructed  with  a  deep  but  strong  bowl, 


BONE    CUTTING    FORCEPS. 


383 


thus  supplying  an  admirable  pattern  for  general  use.     The  handle  is  trans- 
versely serrated  and  furnishes  a  good  grip.     Its  length  is  about  7  inches. 

Frank's  Periosteal  Elevators,  as  outlined  in  figure  849,  consist  of  strong 
flattened  shafts  slightly  curved  upon  the  flat  and  with  well-rounded  tips. 
The  outer  margins  of  the  blades  are  oval,  while  the  upper  or  inner  surfaces 
are  ground  flat,  supplying  a  somewhat  cutting  edge,  well  adapted  for  sepa- 
arating  periosteum  from  bone.  Two  curves  are  provided,  as  shown  in  cross 


Figure  849.    Frank's  Periosteal  Elevators. 

sections  by  "A"  and  "B, "  the  latter  well  adapted  for  dissecting  around 
small  bones  and  in  operations  involving  the  inferior  maxilla.  Two  widths 
of  each  shape  maybe  purchased,  the  smaller  10  and  the  larger  15  millimeters 
in  breadth. 

Bone  Cutting  Forceps. 

These  are  strongly  built  cutting  pliers  or  nippers,  designed  for  severing 
the  smaller  bones,  trimming  fragments,  etc. 


Figure  850.    Liston's  Straight  Bone  Forceps. 

In  some  of  their  various  forms  they  are  necessary  in  a  large  percentage 
of  operations  in  which  bone  is  involved.  They  may  be  employed  to  make  a 
complete  section  of  one  or  more  of  the  smaller  bones,  and  in  such  cases  are 
to  be  preferred  to  the  saw,  because  the  operation  can  be  performed  much 
more  speedily,  does  not  necessitate  so  much  cutting  of  the  soft  tissues,  and 


Figure  851.     Liston's  Curved  Bone  Forceps. 

requires  no  steadying  by  an  assistant.  They  are  useful  in  severing  bones 
in  many  locations  where  it  is  difficult  to  operate  a  saw,  and  they  may  be 
employed  to  cut  away  bone  spiculae  and  other  structures  not  amenable  to 
the  use  of  the  scalpel.  Care  should  be  taken  in  purchasing  to  see  that  the 


Figure  852.    Liston's  Bone  Forceps,  Angular  or  Knee  Bent. 

edges  when  the  forceps  are  closed  form  a  perfectly  tight  joint,  otherwise  in 
cutting  away  many  of  the  soft  tissues,  they  will  not  make  a  smooth  and 
complete  excision.  They  should  never  be  employed  to  cut  metal. 


384  BONE    AND    JOINT    SURGERY. 

Listen's  Straight  Bone  Forceps,  as  outlined  in  figure  850,  represent  the 
plain  straight  pattern  ordinarily  in  use.  They  are  applicable  in  a  large 
majority  of  cases  where  these  instruments  are  required.  The  usual  lengths 
are  7^,  8  and  n  inches. 

Liston's  Curved  Bone  Forceps,  as  illustrated  in  figure  851,  are  curved  on 
the  flat.  They  may  often  be  employed  in  cases  where  straight  forceps 
might  not  answer.  They  may  usually  be  procured  in  7^  and  9  inch 
lengths. 

Liston's  Angular  or  Bent  on  the  Edge  Forceps,  as  shown  in  figure  852, 


Figure  853.    Satterlee's  Bone  Forceps. 

have  had  large  sale  because  they  can  be  advantageously  employed  in  many 
special  cases.  They  are  of  greater  value  than  either  of  the  patterns  pre- 
viously shown,  in  making  deep-seated  resections,  for  instance,  of  the 
scapula,  clavicle  or  maxillary  bones.  For  this  reason  special  instruments 
of  great  strength  have  been  constructed,  as  with  them  even  the  most  "des- 
perate" surgical  case  may  be  attempted.  They  may  be  purchased  in  7^, 
9  and  n  inch  lengths. 


Figure  854.    Velpeau's  Bone  Cutting  Forceps. 

Satterlee's  Bone  Forceps,  as  depicted  in  figure  853,  are  constructed  with 
a  transverse  cutting  edge.  They  differ  materially  from  the  pattern  of  Listen, 
because  the  edges  are  parallel  with  each  other  when  open  and  when 
closed. 

While  we  do  not  know  that  this  is  of  any  special  value  in  general  work, 
special  cases  appear  from  time  to  time  in  which  it  might  be  found  to  be  of 
advantage.  The  usual  size  is  7^  inches  in  length. 


Figure  855.    Hamilton's  Heavy  Bone  Forceps. 

Velpeau's  Bone  Cutting  Forceps,  as  represented  in  figure  854,  are  really 
Satterlee  forceps  curved  upon  the  flat.  This  form  still  retains  the  advan- 
tages of  a  cutting  surface  on  a  line  with  the  axis  of  the  handles.  The  reg- 
ular length  is  8^  inches. 

Hamilton's  Bone  Cutting  Forceps,  as  shown  in  figure  855,  are  intended  to 
overcome  some  of  the  difficulties  encountered  whenever  an  attempt  is  made 


RIB    SHEARS. 


385 


to  cut  the  larger  bones  with  forceps.  Instead  of  the  plain  straight  edge 
common  to  the  older  patterns,  the  cutting  edges  are  in  the  form  of  a  series 
of  serrations,  each  projection  forming  a  tooth  similar  to  that  of  a  saw. 
As  the  instrument  is  strong  and  heavy,  the  operator  can  at  once,  by  a 
combined  piercing,  cutting  and  crushing  force  and  with  ordinary  muscular 
effort  cut  away  large  sections  of  bone.  The  usual  length  is  about 
13^  inches. 

Bib  Shears. 

As  these  instruments  are  intended  for  cutting  a  special  class  of  bones, 
they  might  be  included  under  the  general  heading  of  bone  forceps,  although 
they  are  somewhat  different  in  construction.  In  cutting  a  rib,  there  is  no 
tendency  to  lateral  displacement  of  the  severed  portions;  these  appliances, 
therefore,  are  constructed  with  thin  cutting  blades,  that  they  may  the  more 


Figure  856.     Plain  Rib  Shears. 

easily  be  forced  through  the  structures  of  the  rib.  The  posterior  blade  is 
usually  quite  narrow  and  somewhat  curved,  that  it  may  readily  be  passed 
underneath  the  rib  to  be  severed. 

The  Plain  Rib  Shears,  set  forth  in  figure  856,  represent  one  of  the 
simpler  patterns.  As  it  has  strong  jaws,  with  a  narrow  curved  posterior 
blade,  it  exhibits  the  necessary  qualifications  of  a  good  instrument.  The 
usual  length  is  10  inches. 


Figure  857.     Lucke's  Rib  Shears. 


Lucke's  Rib  Shears,  as  delineated  in  figure  857,  exhibit  an  example  of  the 
old  and  well-known  toggle  joint  in  a  somewhat  modified  form.  It  is  here 
applied  to  force  a  cutting  blade  outward.  The  posterior  blade  is  sharply 
curved  and  on  its  proximal  side  is  provided  with  a  central  groove  to  receive 
the  knife  blade  when  forced  outward  by  the  compression  of  the  handles. 
With  this  device  a  rib  may  be  cut  with  the  exercise  of  little  force.  Its 
length  is  about  10  inches. 

Gouging-  or  Gnawing  Forceps. 

These  are  constructed  with  hollow  sharp-edged  jaws  for  "biting"  out 
sections  of  diseased  bone  in  pieces.  They  may  be  employed  in  cases  where 
the  structures  are  too  firm  to  be  crushed  or  loosened  with  a  scoop.  They 
are  adapted  for  removing  not  only  carious  bone,  but  angular  projections 
and  sharp  spiculae  of  healthy  osseous  structures.  To  accomplish  this  they 

26 


386 


BONE    AND    JOINT    SURGERY. 


must  be  strong ;  the  cutting  edges  should  be  quite  sharp,  and  must  in  all 
cases  meet  or  approximate  accurately. 

Luer's  Straight  and  Curved  Bone  Gouging  Forceps,  as  illustrated  in 
figures  858  and  859,  combine  all  the  requirements  of  perfect  instruments. 
They  are  as  narrow  as  possible  consistent  with  the  provision  of  space  for 


Figure  858.    Luer's  Straight  Bone  Gouging  Forceps. 


Figure  859.     Luer's  Curved  Bone  Gouging  Forceps. 

cavities  in  the  forceps  blades  of  a  size  sufficient  to  grasp  and  hold  any 
excised  masses.  They  are  usually  about  6^  inches  in  length,  and  are  the 
smallest  and  lightest  of  bone  gouging  forceps. 

Darby's  Bone  Gouging  Forceps,  as  represented  in  figure  860,  differ  from 


Figure  860.    Darby's  Bone  Gouging  Forceps. 

Luer's  curved  forceps  principally  in  being  larger,  longer  in  the  curves  and 

in  having  a  greater  cutting  surface.     The  length  is  usually  about  8  inches. 

Hoffman's  Cranial  Bone  Gouging  Forceps,  as  displayed  in  figure  86 1,  have 

one  blade  fenestrated  so  that  detached  portions  of  bone  may  pass  directly 


Figure  861.    Hoffman's  Crania!  Bone  Gouging  Forceps. 


through  the  opening  into  which  they  are  forced  by  the  biting  action  of  the 
jaws.  The  blades  being  slightly  knee  bent,  the  handles  are  easily 
adapted  to  the  shape  of  the  surrounding  parts.  They  are  usually  about 
7  inches  in  length. 

Bone  Holding  Forceps. 

These  are  strongly  built  and  provided  with  special  jaws  and  teeth 
adapted  for  grasping  a  bone  in  its  continuity.  They  may  be  required  for 
holding  a  bone  either  in  sections  or  its  entirety.  They  will  be  found  of 
"value  in  grasping  bones  and  for  use  in  many  cases  where  a  firm  grip  with  the 
hands  can  not  be  obtained. 


BONE    HOLDING    FORCEPS.  387 

Hamilton's  Bone  Holding  Forceps,  as  manifest  in  figure  862,  is  a  short 
and  somewhat  strong  pattern,  provided  with  sharply  serrated  teeth.  It  is  a 
desirable  instrument  for  removing  or  holding  splinters  of  bone,  as  it  affords 
a  firm  grasp.  Its  length  is  about  8  inches. 


Figure  862.    Hamilton's  Bone  Holding  Forceps. 


Ferguson's  Bone  Holding  Forceps,  as  detailed  in  figure  863,  is  particularly 
adapted  to  grasping  and  holding  the  shaft  of  a  long  bone.  It  has  two  rows 
of  teeth,  between  which  the  bone  should  pass  transversely.  When  clasped 
with  a  firm  grip,  the  construction  of  these  teeth  is  such  as  to  enable  the 
operator  to  control  the  movements  of  the  bone.  Its  length  is  8^  inches. 


Figure  863.    Ferguson's  Bone  Holding  Forceps. 

Mathieu's  Multiple  Point  Bone  Holding  Forceps,  as  explained  in  figure 
864,  consists  of  a  forceps  provided  with  slotted  jaws,  each  so  arranged  that 
it  presents  six  strong  yet  sharp  teeth  with  which  to  contact  and  hold  a 
bone.  The  instrument  is  of  strong  construction  and  so  shaped  that  with  it 


Figure  864.    Mathieu's  Multiple  Point  Bone  Holding  Forceps. 

a  bone  of  almost  any  size  and  shape  may  be  securely  held,  even  when 
wholly  or  partially  separated  from  the  soft  tissues.  Its  usual  length  is 
about  10  inches. 

Mathieu's  Circular  Prong  Bone  Holding  Forceps,  as  described  by  figure 
865,  is  provided  with  jaws  in  the  form  of  slender,  full  curved  prongs,  four  in 


Figure  865.    Mathieu's  Circular  Prong  Bone  Holding  Forceps. 


number,  each  pair  of  which  rests  in  the  same  plane  or  radius.  With  this 
instrument  a  bone  may  be  held  without  being  separated  from  the  soft  parts. 
The  latter,  if  not  lying  too  deeply  over  the  bone,  may  be  penetrated  and  the 
forceps  utilized  to  secure  immobilization. 


388 


BONE    AND    JOINT    SURGERY. 


Sequestrum  Forceps. 

These  are  used  for  holding  or  removing  the  detached  portion  of  bone 
forming  a  sequestrum.  They  should  be  strongly  built,  with  medium  length 
jaws  and  provided  with  serrated  teeth. 

Hamilton's  Sequestrum  Forceps,  as  drawn  in  figure  866,  consists  of  a  plain, 
straight  pattern  of  medium  weight  with  short  and  somewhat  heavy  jaws. 


Figure  866     Hamilton's  Sequestrum  Forceps. 


As  it  is  of  the  scissors  handle  type,  it  is  not  suitable  for  removing  the 
heavier  sequestra,  for  the  grasping  power  is  not  as  great  as  it  would  be 
were  the  entire  hand  employed.  It  is  adapted  more  particularly  to 
the  lighter  operations.  Its  length  is  8*4  inches. 


Figure  867.    Van  Buren's  Sequestrum  Forceps. 

Van  Buren's  Sequestrum  Forceps,  as  delineated  in  figure  867,  is  perhaps 
the  most  popular  pattern  of  this  class  of  forceps.  As  it  is  constructed  with 
bayonet-shaped  jaws,  it  can  easily  be  introduced  into  almost  any  cavity, 
even  a  deep-seated  one.  Its  weight  is  sufficient  to  meet  any  demands  that 
may  be  made  upon  it,  and  its  length  is  8^  inches. 


Figure  863.     Curved  Sequestrum  Forceps. 

The  Curved  Sequestrum  Forceps,  traced  in  figure  868,  is  a  short,  strong 
forceps,  constructed  with  jaws  curved  downward  on  the  edge.  Its  length  is 
usually  about  7  y2  inches. 

Bone  Hooks. 

These  are  an  extra  heavy  variety  of  tenaculum.  They  are  frequently 
employed  to  hook  into  and  hold  a  sequestrum,  to  draw  or  assist  in  drawing 
it  from  its  bed,  or  to  hold  a  fragment  of  carious  bone  while  being  detached 


Figure 


Bone  Hook. 


by  saw  or  cutting  forceps.     They  should  be  strongly  built  of  good  steel 
and  with  handles  of  large  size. 

The  Bone  Hook  sketched  in  figure  869  exhibits  the  regular  pattern  and 
answers  all  requirements.     The  usual  length  is  8  inches. 


BONE    DRILLS. 


389 


Bone  Drills. 


These  consist  of  some  form  of  drill  and  mechanism  by  which  it  may  be 
rotated.  They  are  employed  in  some  cases  of  excisions  to  bore  the  holes 
necessary  to  wire  together  the  osseous  coaptating  surfaces,  that  during 
regeneration  there  may  be  no  displacement  of  the  parts.  They  are  also 


Figure  870.    Langenbeck's  Drills. 


used  in  cases  of  suppurative  osteomyelitis  and  similar  complications  where 
it  is  desirable  to  open  the  medullary  canal  to  allow  the  escape  of  confined 
pus,  and  in  wiring  fractured  bones.  The  larger  burr-shaped  drills  are  oc- 
casionally utilized  to  cut  away  diseased  portions  of  bone  where,  owing  to  their 


Figure  871.    Hamilton's  Bone  Drills  with  Guard. 

deep-seated  location  or  narrowness  of  the  tract,  the  operator  finds  he  is 
unable  to  remove  them  with  scoop  or  gouge. 

Langenbeck's  Drill,  as  depicted  in  figure  870,  is  similar  to  an  ordinary 
carpenter  brace.  Three  drills  of  varying  sizes  are  provided.  The  width 
of  the  drill  points  are  2,  3  and  4  millimeters  each.  The  length  of  the 
brace  is  n  inches,  and  complete  with  drill  14  inches. 


Figure  872.    Brainard's  Bone  Drills. 


Hamilton's  Bone  Drill,  as  portrayed  in  figure  871,  is  an  improvement  on 
the  preceding  pattern  in  many  particulars.  It  occupies  much  less  space 
and  the  drills  may  be  safely  stored  in  the  hollow  metal  handle.  It  is  pro- 
vided with  a  guard  to  prevent  penetration  beyond  the  required  depth.  The 
shaft  operated  by  a  suitable  handle  may  be  rotated  on  the  principle  of  the 


390 


BONE    AND    JOINT    SURGERY. 


spiral  incline.  This  instrument  includes  six  drills,  the  diameter  of  the  drill 
heads  varying  from  i  *^  to  4  millimeters,  the  total  length  of  the  instrument 
being  9  inches. 

Brainard's  Bone  Drills,  as  defined  in  figure  872,  are  plain  and  compact 
and  comprise  three  drills,  one  shaft  and  one  burr.  The  diameters  of  the 
drills  are  2,  3  and  4,  and  the  diameter  of  the  burr  at  the  largest  part  is 
10  millimeters.  The  shaft  is  intended  as  a  holder  for  the  ordinary  short 
mechanic's  drills,  such  as  may  be  procured  in  hardware  stores.  They 
may  be  found  in  quite  a  variety  of  shapes  and  sizes,  and  can  be  purchased 
at  an  exceedingly  low  price.  This  additional  feature  renders  the  combina- 
tion a  good  one. 

Drill  Trephines. 

These  differ  from  plain  drills  in  that  they  cut  from  a  bone  a  circular 
piece  of  a  size  to  correspond  with  the  lumen  of  the  trephine  chamber. 
They  work  upon  the  same  general  principle  as  a  core  drill.  They  are 
employed  in  cases  where  large-sized  openings  extending  into  the  medullary 
canal  are  necessary  to  afford  escape  for  pus,  or  where  one  or  more  holes 
through  the  involucrum  are  required  in  order  to  gain  a  starting  point  for 
work  with  a  chisel,  gouge,  or  saw. 

Collin's  Drills,  as  evidenced  by  figure  873,  consist  of  five  assorted  sizes 
of  drills,  three  assorted  forms  of  burrs  and  four  assorted  sizes  of  bone 


Figure  873.    Collin's  Drills  and  Drill  Trephines. 

trephines,  contained  in  a  metal  case.     The  drills,  burrs  and  trephines  all 
fit  a  universal  shaft  and  handle. 

The  drills  are  operated  by  a  geared  handle  so  adjusted  as  to  furnish  a 
rapid  motion  if  desired.  The  crank  handle  is  attached  with  a  ball  and 
socket  joint,  thus  permitting  of  close  folding  in  packing.  The  bone 
trephines  are  all  guarded  so  that  the  penetrating  distance  of  both  the 
central  shaft  and  trephines  may  be  regulated.  The  drills  are  from  2  to  4, 
the  burrs  from  10  to  18,  and  the  trephines  from  5  to  8  millimeters  in  diam- 
eter, while  the  entire  length  of  the  instrument  is  about  8%  inches. 

Surgical  Motors  and  Engines. 

These  are  required  in  many  surgical  procedures,  principal  among  which 
are  operations  on  the  skull  and  other  bones,  and  the  removal  of  the  turbin- 
ated  bones.  While  an  electrical  motor  is  to  be  preferred,  foot  engines  are 
frequently  employed.  The  latter  do  not  differ  from  those  ordinarily  used 


SURGICAL    MOTORS  AND    ENGINES. 


391 


by  dentists  excepting  that  they  should  be  provided  with  burrs  and  drills 
particularly  adapted  to  surgical  work. 

The  Surgical  Motor,  illustrated  in  figure  874,  consists  of  a  |  horse-power 
motor  regulated  by  a  combined  rheostat  and  foot  switch  that  may  be  moved 
to  any  position  on  the  floor.  With  a  slight  movement  of  the  foot  the 


Figure  874.    Electric  Motor  for  Surgical  Use. 


engine  may  be  caused  to  run  forward,  reverse  or  stop  instantly.  It  may 
be  placed  in  a  room  with  the  operator  or  in  an  adjoining  room.  It  may  be 
connected  direct  with  a  cable  or  adjusted  to  a  ceiling  bracket.  The  latter 
are  most  desirable  as  they  do  not  occupy  valuable  space  in  the  operating- 


Figure  875.    Ceiling  Bracket,  for  Use  with 
Surgical  Engine. 


Figure  876.     Surgical  Foot  Engine. 


room.  They  can  be  supplied  for  almost  any  form  of  electrical  current  and, 
when  once  installed,  furnish  the  best  means  for  operating  surgical  drills, 
burrs,  trephines,  etc. 

The  Ceiling  Bracket,  for  use  with  the  surgical  engine,  exhibited  in  figure 


392 


BONE    AND    JOINT    SURGERY. 


875,  is  provided  at  its  upper  end  with  a  universal  joint  that  allows  of  free 
movement  in  any  direction.  The  adjustment  is  such  that  the  bracket  will 
remain  in  any  position  in  which  it  may  be  placed.  Its  mechanism  com- 
prises two  pulleys,  both  of  which  are  noiseless  and  self-oiling.  The  lower 
portion  of  the  bracket  is  constructed  with  a  telescoping  section  by  which 
the  belt  is  always  taut  and  by  which  the  engine  head  may  be  placed  at  any 
desired  height.  This  bracket  may  be  used  with  either  water  or  electric 
motors. 

The  Surgical  Foot  Engine,  delineated  by  figure  876,  is  of  light  construc- 
tion with  phosphor-bronze  bearings  that  operate  with  only  slight  friction. 


Figure  877.    Surgical  Hand  Piece. 

The  upright  section  is  controlled  by  an  adjustable  spring  for  rocking.  The 
mechanism  is  such  that  the  engine  does  not  stop  on  the  center.  The  device 
for  raising  and  lowering  the  head-piece  is  of  ingenious  mechanism  and 
effective. 

The  Surgical  Hand  Piece,  as  set  forth  in  figure  877,  is  arranged  to  firmly 
hold  such  drills,  burrs,  and  trephines  as  are  required  for  surgical  work. 
The  chuck  attachment  is  automatic  and  of  such  construction  as  to  require 
practically  no  attention.  It  is  provided  with  mechanism  so  that  even  when 
well  worn  its  parts  may  be  adjusted  so  that  the  instrument  will  be  prac- 


D        E 

Figure  878. 


H       J 

F          G          H          I  J  K 

Surgical  Drills,  Burrs  and  Trephines. 


M 


tically  as  good  as  new.  The  chuck  is  opened  and  closed  by  a  downward 
pressure  on  the  sliding  collar.  This  simple  device  avoids  the  annoyance 
caused  by  the  accidental  opening  of  the  chuck  while  in  use. 

Surgical  Drills,  as  represented  in  figure  878,  need  not  differ  from  patterns 
usually  employed  in  bone  surgery.  They  may  be  of  any  desired  size. 

Surgical  Burrs,  pictured  in  figure  878,  may  be  either  olive  shaped  or  in 
cylindrical  form,  the  former  being  generally  preferred. 

Surgical  Trephines,  as  shown  in  figure  878,  may  be  either  plain  or 
guarded,  the  latter  being  particularly  adapted  for  nasal  surgery. 


SKULL  TREPHINES. 


393 


Trephine  Brushes. 

These  consist  of  small  flat  brushes  employed  to  dislodge  bone  dust  from 
the  track  of  the  trephine. 

The  Trephine  Brush,  exhibited  in  figure  881,  consists  of  a  small,  flat  metal- 


Trephine  Brush. 


lie  handle  that  contains  two  rows  of  bristles  of  good  quality.  A  brush  of  this 
kind  should  accompany  every  trephine,  although  tooth  and  hand  brushes 
are  occasionally  used  instead. 

Skull  Trephines. 

While  the  skull  may  be  safely  perforated,  or  an  opening  in  it  enlarged 
with  chisel  or  gouge  and  mallet,  many  surgeons  prefer  to  employ  a  special 
instrument,  called  a  trephine.  This  is  a  species  of  auger  or  bit,  so  constructed 
that  with  it  a  circular  piece  may  be  cut  from  a  bone.  They  are  employed 
for  cutting  away  badly-shattered  parts  surrounding  a  seat  of  fracture, 
enlarging  a  perforation,  or  for  providing  an  opening  into  the  brain  to  assist 
in  making  a  diagnosis,  to  relieve  pressure,  or  to  permit  some  further  oper- 


Figure  883.    Crown  Trephines  with  Guard. 


Figure  883.    Gait's  Conical  Trephine. 


ation.  They  consist  of  a  short  cylinder  of  steel  attached  to  a  shaft.  The 
lower  border  of  the  cylinder  is  formed  into  sharp  teeth  of  suitable  size  and 
shape.  The  bone  is  cut  by  rotation  of  the  trephine,  during  which  inward  or 
downward  pressure  on  the  handle  is  necessary. 

Most  patterns  of  trephines  are  constructed  with  a  center  pin,  which,  like 
the  point  of  a  "bit"  or  auger,  serves  to  center  the  instrument  and  insure  its 
"tracking,"  thus  keeping  it  in  position.  This  center  pin  is  usually  trocar- 
pointed  and  adjustable,  that  it  may  be  contained  within  the  trephine  shaft 
and  extended  as  desired.  For  use  in  ordinary  cases  it  is  set  so  that  it 


394 


BONE    AND    JOINT    SURGERY. 


extends  about  TV  of  an  inch  beyond  the  outer  limits  of  the  trephine  teeth. 
As  the  instrument  is  rotated  from  left  to  right,  a  hole  is  bored  with  this 
pin,  which  serves  as  a  shaft  around  which  the  trephine  is  revolved.  As 
soon  as  a  groove  is  cut  of  sufficient  depth  to  hold  the  instrument  in  place, 
the  center  pin  should  be  withdrawn,  for  if  not,  on  complete  perforation,  the 
dura  mater  or  other  soft  tissues  within  the  skull  might  be  unnecessarily 
injured.  Trephines  constructed  with  sliding  center  pins  are  difficult  to 
cleanse,  particularly  if  blood  or  other  matter  be  allowed  to  enter  the  hollow 
shaft.  Owing  to  the  large  quantity  of  infected  matter  that  might  be  con- 
tained in  one  of  these  instruments,  great  care  should  always  be  exercised  in 
cleansing  them. 

It  is  evident  that  the  less  bone  substance  destroyed  by  the  sawing  action 
of  the  teeth  the  better,  hence  all  forms  of  trephines  should  be  constructed 


Figure  884.    Roberts'  Separable 
Trephine. 


Figure  885.    Andrews'  Long 

Trephine  for  Opening  the 

Gasserian  Ganglion. 


Figure  886.    Roberts'  Segment 

Trephine  for  Enlarging  the 

First  Opening. 


with  walls  as  thin  as  is  consistent  with  the  necessary  strength,  that  the 
track  or  groove  be  as  narrow  as  possible. 

The  Crown  Trephines  with  Guard  are  shown  by  figure  882.  This 
pattern,  at  first  constructed  without  the  guard,  formed  for  many  years  the 
standard  instrument  for  opening  the  skull.  Later  the  guard  was  found 
useful  in  marking  the  distance  to  be  traversed  by  the  trephine,  thus  pre- 
venting the  instrument  from  suddenly  breaking  through  its  self-made 
opening.  This  guard  is  so  arranged  as  to  be  set  at  any  desired  height. 
Plain  crown  trephines,  though  now  little  used,  can  still  be  purchased. 
Those  with  guard  are  kept  in  a  larger  variety  of  sizes,  usually  in  diameters 
of  24,  "/%  and  i  inch. 

Gait's  Conical  Trephine,  shown  by  figure  883,  is  generally  considered 
an  improvement  on  the  crown  pattern.  The  outside  of  this  trephine  is 
conical,  its  smallest  diameter  being  at  the  bottom.  Teeth  are  cut  in  the 
lower  margin  somewhat  on  the  plan  of  those  found  in  the  former  pattern. 


SKULL    TREPHINES. 


395 


The  indentations  between  these  teeth,  however,  extend  in  deeply  cut  serra- 
tions over  to  and  along  the  outside  of  the  cylinder  in  a  right,  oblique  up- 
ward direction.  The  instrument  is  thus  provided  with  an  external  cutting 
surface  which,  as  long  as  the  turning  is  persevered  in,  continues  to  enlarge 
the  opening  on  the  lines  of  its  first  incision.  This  opening  corresponds  in 
size  and  shape  to  the  trephine,  and  being  smaller  at  the  bottom,  there  is  no 
danger  (if  a  proper  degree  of  caution  be  used)  of  injuring  either  the  dura 
mater  or  the  tissues  which  underlie  it.  They  may  usually  be  purchased  in 
diameters  of  ^,  ^,  /6  and  i^  inches. 

Roberts'  Separable  Trephine,  as  illustrated  by  figure  884,  is  an  improve- 
ment on  the  older  forms.  As  before  stated,  both  the  crown  and  Gait's 
trephines  are  instruments  difficult  to  clean,  the  sliding  central  shaft  and 
trephine  chamber  of  these  patterns  furnishing  corners  and  crevices  that 
can  not  be  reached  with  brush  or  cloth.  Roberts,  after  some  experiments, 
succeeded  in  producing  a  pattern  separable  in  all  its  parts,  thus  overcoming 


Figure  887.    Roberts'  Set  Aseptible  Trephines. 

an  objection  often  before  made  to  this  class  of  instruments.  The  center 
pin  of  the  older  forms  is  here  replaced  by  a  short  solid  arm  attached  to  an 
inner  shaft  of  solid  metal.  A  short  bar,  projecting  downward,  and  a  slot 
in  the  movable  cylinder  furnish  means  for  rotating  the  latter  with  the 
cutting  portion.  The  handle  of  this  pattern  is  longer  upon  one  side  than 
the  other.  It  is  attached  to  the  shaft  in  this  manner,  so  as  to  rotate  con- 
centrically with  the  hand.  This  is  because  the  hypothenar  side  of  the 
palm  requires  a  longer  lever  than  the  thenar.  They  may  be  procured  from 
^4  to  i  ^  inches  in  diameter,  the  ^  inch  size  being  usually  preferred. 

Roberts'  Set  of  Trephines,  as  exhibited  in  figure  887,  represents  three  of 
the  most  useful  sizes  in  combination  with  a  single  handle,  all  contained  in  a 
hardwood  case. 

Andrews'  Trephine,  as  shown  by  figure  885,  was  designed  particularly 
for  operations  on  the  Gasserian  ganglion.  In  general  form  it  does  not 
differ  from  the  pattern  of  Gait,  excepting  that  the  opening  is  but  y2  inch  in 
diameter,  while  the  shaft,  including  the  trephine  head,  is  5  inches  in  length. 
Besides  being  adapted  for  the  above-mentioned  purpose  it  may  be  employed 
for  general  work. 


396 


BONE    AND    JOINT    SURGERY. 


Roberts'  Segment  Trephine  was  designed  for  deepening  any  portion  of 
the  groove  surrounding  the  button  or  bone  to  be  removed  without  neces- 
sarily cutting  throughout  the  entire  channel.  It  is  thus  adapted  for  remov- 
ing sections  from  points  where  the  skull  is  thicker  upon  one  side  than  upon 
the  other.  With  a  cylindrical  trephine  such  buttons  can  be  removed  only 
by  tilting  the  instrument,  for  otherwise  the  membranes  underneath  the 
thinner  portions  might  be  injured.  With  an  instrument  like  that  shown  by 
figure  886,  this  difficulty  may  be  overcome.  In  this  pattern  the  cutting 
edge  extends  from  one-quarter  to  one-third  of  the  circumference.  As  the 
center  pin  does  not  require  retraction,  it  is  immovably  fixed  in  the  shaft  of 
the  trephine.  The  chief  objection  to  this  instrument  is  the  fact  that  it  must 


Figure  888.    Bernays'  Trephine. 


Figure  889.    Devilbiss'  Trephine. 


be  of  the  same  diameter  as  the  circular  trephine  employed,  thus  involving 
considerable  expense  if  various  sizes  are  procured. 

Bernays'  Trephine,  as  sketched  in  figure  888,  may  be  utilized  for  remov- 
ing circular,  oval  and  various  shaped  sections  from  the  convexity  of  the 
skull.  It  may  be  used  as  an  ordinary  trephine,  and  with  it  discs  YZ  to  2^ 
inches  in  diameter  may  be  removed.  If  pieces  of  a  form  other  than  cir- 
cular require  removal,  it  may  be  utilized  for  cutting  grooves  of  any  desired 
length.  A  single  incision  may  be  employed  for  cutting  the  base  of  a 
wedge-shaped  splinter  by  simply  turning  the  instrument  back  and  forth 
within  the  required  limits ;  or  two  concave  fissures  may  be  formed,  each 
facing  the  other,  and  their  ends  united  with  a  bone  chisel. 

The  instrument  is  provided  with  three  bits,  a  narrow,  sharp-pointed  one 
being  used  for  forming  the  first  incision  in  the  external  table,  this  to 
be  followed  by  a  broader  and  the  latter  with  one  having  a  round  cutting 
point.  If  a  broad-edged  bit  be  used  when  approaching  the  dura  mater 
there  will  be  no  likelihood  of  injuring  the  membrane. 

Cranial  Gouging  Forceps. 

Forceps  for  gouging  or  cutting  away  the  skull  differ  from  ordinary  bone 
gouging  and  cutting  forceps  in  having  one  thin,  slender  jaw  that  may  be 


CRANIAL    GOUGING    FORCEPS. 


397 


passed  underneath  or  inside  the  opened  skull.  With  a  strong-  pair  of  these 
forceps  large  areas  of  bone  may  be  quickly  removed. 

Devilbiss'  Cranial  Gouging  Forceps,  as  set  forth  in  figure  890,  are  intended 
to  replace  the  trephine  in  operations  where  extensive  areas  or  irregular  sec- 
tions of  bone  require  removal.  They  consist  of  forceps-shaped  handles,  the 
upper  blade  ending  in  a  strong  fenestrated  jaw,  the  under  surface  of  which 
is  sharpened  to  a  cutting  edge.  Attached  to  the  opposite  handle  and  ply- 
ing through  the  fenestra  is  a  removable  shaft,  terminating-  at  its  lower 
margin  in  a  curved  projection  of  such  shape  as  to  form  a  bite  with  the  lower 
border  of  the  fenestra  before  referred  to. 

In  order  to  operate  with  this  instrument  it  is  first  necessary  to  bore  with 
a  drill  or  bone  trephine  an  opening  through  the  skull  sufficiently  large  to 
admit  the  lower  jaw  of  the  forceps.  The  under  surface  of  the  latter  is 
smooth,  well  rounded,  and  serves  to  separate  the  dura  mater  from  the  skull. 
By  compressing  the  handles  the  instrument  will  bite  or  punch  from  the 
skull  any  portion  included  in  the  grasp  of  the  forceps.  As  this  force  is 
exerted  from  below  upward,  the  separated  portion  is  immediately  forced 
out  of  the  wound,  passing  up  through  the  opening  in  the  female  blade. 


Figure  890.    Devilbiss'  Cranial  Gouging  Forceps. 

With  this  instrument  a  slit  y1^  to  ^  of  an  inch  in  width  may  be  cut  in 
any  direction,  thus  enabling  the  operator  to  remove  a  piece  of  such  size 
and  shape  as  the  nature  of  the  case  demands.  The  edge  of  the  cut  bone 
will  be  found  smooth  and  fairly  regular,  and  the  leverage  is  such  that  it  can 
be  used  without  undue  exertion.  It  is  particularly  adapted  for  the  forma- 
tion of  the  trap-door  operation,  because  the  amount  of  bone  tissue  removed 
is  small  and  with  it  there  is  less  danger  of  injuring  the  soft  structures. 

Devilbiss'  Trephine,  as  expressed  in  figure  889,  is  particularly  intended 
for  use  with  the  rongeur  forceps  illustrated  by  figure  890.  It  differs  from 
the  pattern  of  Roberts  in  being  much  smaller  and  so  arranged  that  the 
central  pin  projects  backward  into  the  shaft  of  the  instrument,  where  it  is 
held  in  position  by  finger  pressure,  rotation  being  prevented  by  a  projecting 
flange. 

The  instrument  is  conical  in  form,  its  smallest  external  diameter  being 
about  %  of  an  inch.  While  it  is  used  principally  for  the  insertion  of  the 
forceps  blade  above  referred  to,  it  may  be  employed  in  any  case  where  a 
small  trephine  is  required. 

Cranial  Elevators. 

These  are  intended  for  use  in  cases  of  fractures  of  the  skull,  for  raising 
depressed  sections  to  their  proper  level.  They  are  of  two  varieties,  levers 
and  screws. 


398 


BONE    AND     JOINT    SURGERY. 


Cranial  Elevating  Levers  consist  of  short,  strong  instruments,  suitable 
for  passing  into  the  crevice  caused  by  a  fracture  and  using  the  normal  side 
as  a  fulcrum,  thus  raising  the  depressed  portions.  When  the  opening  is 
not  wide  enough  to  admit  the  elevator  so  that  it  may  be  passed  under  the 
fragment  to  be  raised,  the  space  may  be  enlarged  by  cutting  out  a  piece  of 
the  bone  with  the  saw  or  trephine,  or  clipping  off  fragments  with  a  bone- 
cutting  or  gouging  forceps. 


Figure 


Trephining  Elevator  and  Raspatory. 


The  Trephining  Elevator  and  Raspatory,  sketched  in  figure  891,  is  prob- 
ably more  useful  than  any  other  form.  It  is  a  combined  cranial  bone  and 
periosteal  elevator.  The  end  intended  for  use  as  a  bone  lever  is  pointed 
and  flat  upon  one  side,  this  side  being  transversely  serrated  to  prevent  its 
slipping.  The  end  formed  into  a  raspatory  is  well  shaped  for  peeling  back 
the  periosteum  of  the  skull.  It  will  also  be  found  useful  in  raising  the 
circle  of  bone  cut  out  by  the  trephine.  Its  length  is  about  6%  inches. 


Figure  892.     Screw  Elevator. 


Cranial  Screw  Elevators  will  be  found  useful  in  raising  slender  frag- 
ments of  depressed  bone  wherever  found.  They  may  be  screwed  into  the 
bone,  thus  obtaining  a  firm  hold  upon  the  portion  to  be  raised. 

The  Screw  Elevator,  described  in  figure  892,  may  be  used  for  raising  a 
broken  fragment  of  bone.  It  is  particularly  adapted  for  use  on  the  zyg- 
omatic  process,  the  antrum,  and  in  fractures  of  the  skull.  That  its  use 
may  not  produce  undue  pressure,  the  engaging  screw  point  is  sharp  and 
finely  threaded.  The  usual  length  is  5  to  6  inches. 

Bone  Chips. 

Decalcified  Bone  Chips,  as  devised  by  Senn,  are  now  extensively 
employed  to  fill  cavities  caused  by  the  removal  of  bone ;  they  are  utilized 
to  bridge  the  space  and  to  aid  the  process  of  repair. 


Figure  894.    Ivory  Peg  for  Uniting 
Fractures,  Etc. 


Figure  895.      Horseshoe  Nail  for  Unit- 
ing Fractures,  Etc. 


Figure  896.    Gerster's  Nail  for  Uniting 
Fractures,  Etc. 


Figure  893.     Showing  4-ounce  Bottle  of 
Senn's  Decalcified  Bone  Chips. 


It  is  claimed  that  they  are  not  only  aseptic  but  antiseptic,  thus  prevent- 
ing local  recurrence,  and  consequent  general  infection.  These  chips  are 
gradually  absorbed  by  the  granulating  tissue,  the  latter  in  due  time  being 


BONE    NAILS.  399 

transformed  into  permanent  bone  structure.  The  wound  usually  heals 
primarily,  and  the  process  of  repair  is  often  so  complete  and  perfect  as  to 
leave  only  an  external  linear  scar. 

Before  implantation  the  cavity  should  be  thoroughly  cleansed  from  all 
necrosed  bone  and  infected  material  and  the  space  filled  with  iodoformized 
chips.  In  the  process  of  the  operation  the  periosteum  should  be  preserved, 
and  after  packing  the  space  with  the  chips,  it  should  be  carefully  replaced 
and  secured  with  buried  sutures.  Should  infection  follow,  a  second  im- 
plantation is  necessary.  They  may  be  procured  in  plain  4  ounce  and  i 
pint  glass  stoppered  bottles. 

Bone  Nails. 

Steel  nails  are  occasionally  employed  in  cases  of  exsection,  particularly 
of  the  knee  joint.  They  may  be  obtained  both  round,  square  and  flat,  and 
of  any  desired  length,  sizes  from  2  to  3  inches  being  usually  preferred. 

From  two  to  four  may  be  driven  diagonally  through  the  approximated 
ends  of  the  excised  bones,  thus  firmly  securing  them  in  apposition.  That 
they  may  serve  to  interlock  the  joint,  it  is  necessary  that  one-half  the  num- 
ber be  driven  in  each  direction. 

In  order  to  avoid  searching  for  the  heads  of  such  nails  when  removal 
becomes  necessary,  it  has  been  advised  that  a  silk  ligature  be  fastened  to 
the  head  of  each  and  allowed  to  protrude  from  the  wound. 

Gerster's  Iron  Nails,  as  shown  in  figure  896,  resemble  ordinary  horseshoe 
nails  in  general  form,  though  unlike  the  latter;  for  surgical  use  they  are 
constructed  from  steel. 

Extension  and  Counter-Extension. 

Appliances  for  these  purposes  are  occasionally  found  necessary  after 
operations  on  bone,  but  as  the  apparatus  required  is  more  frequently 
employed  in  the  treatment  of  fractures,  the  reader  is  referred  to  that  chap- 
ter for  a  description. 


CHAPTER  XIX. 


AMPUTATING. 

With  the  exception  of  the  time-honored  amputation  knives,  all  the 
instruments  that  might  be  classified  under  this  heading  have  been  included 
in  the  chapters  devoted  to  minor  operating  and  bone  surgery.  Many 
surgeons  no  longer  employ  a  knife  larger  than  an  ordinary  scalpel  for  any 
amputation  even  at  the  thigh  or  hip  joint.  The  great  majority  of  oper- 
ators, however,  make  use  of  the  Listen  knives  so  long  in  use  and  still  ad- 
vised in  most  standard  text-books. 

In  addition  to  the  instruments  and  general  appliances  required  for 
minor  operations,  as  described  on  page  270,  the  surgeon  should  provide 
himself  with  the  following  special  instruments: 

Liston's  amputating  knives  for  deep  incisions. 

Listen's  catlin  for  interosseous  incisions. 

Metacarpal  knife  for  minor  amputations. 

Cartilage  knife  for  disarticulations. 

Saws  for  bone  incisions,  see  page  376. 

Periosteal  elevator  for  separation  of  periosteum,  see  page  381. 

Bone-cutting   forceps   for  removing   spiculae,    small   bones,    etc.,    see 
page  383. 

Amputating  Knives. 

These  are  now  generally  constructed  with  hollow  German  silver  handles 
and  steel  shanks  and  blades.  The  latter  are  long  and  somewhat  slender, 
with  a  back  that  is  straight  for  about  ^  of  its  length,  the  distal  quarter 


Figure  897.    Liston's  Amputating  Knife. 

tapering  slightly  toward  the  point.  The  edge  for  about  f  of  its  length 
should  be  straight,  the  distal  £  rounding  off  to  a  point,  shaped  to  a  good 
convexity.  The  length  must  be  in  proportion  to  the  size  of  the  limb  to  be 
removed.  If  for  transfixion,  it  should  be  from  i  ^  to  twice  the  diameter  of 
the  limb  at  the  point  of  amputation. 


Figure  900.     Liston's  Catlin. 

Liston's  Amputating  Knives,  as  exhibited  in  figure  897,  are  of  three 
sizes,  known  as  small,  or  hand  and  foot;  medium,  or  leg  and  arm;  and 
large,  or  hip  and  thigh.  The  usual  dimensions  are  as  follows  : 

Width  of  blade.  Length  of  blade.  Length  of  Knife. 

Small  A  inch  scinches  10^  inches 

Medium        yV     "  6^      "  \\y       " 

Large  "  73/     «  « 

I  74-  13 

400 


AMPUTATING   KNIVES. 


Listen's  Catlins. 


401 


These  consist  of  long  slender  double-edged  knives  used  for  dividing 
tissues  in  the  interosseous  spaces.  When  performing  amputations  of  the 
leg  or  forearm,  a  double-edged  knife  enables  the  operator  to  cut  in  both 
directions,  so  that  when  the  blade  is  forced  through  between  the  openings, 
the  tissues  on  both  sides  may  be  severed  without  withdrawing  the  instru- 
ment. A  single-edged  knife  can  be  used  instead,  by  withdrawing  the  knife 
blade  when  necessary  to  cut  in  an  opposite  direction  from  the  first  incision, 
and  reintroducing  it.  To  attempt  to  turn  the  blade  in  situ  might  result  in 
injuring  some  of  the  soft  tissues. 

Listen's  Catlin,  as  disclosed  in  figure  900,  are  manufactured  by  many 
instrument  makers,  in  sizes  identical  with  the  amputating  knives  before 
described  for  just  what  reason  does  not  appear,  since  a  single  instrument  the 
size  of  a  small  amputating  knife  will  meet  every  indication,  even  in  the 
amputation  of  a  limb  of  largest  size.  Catlins  are  usually  y&  inch  narrower 
than  amputating  knives  of  the  same  length. 

Metacarpal  Knives. 

This  term  is  frequently  employed  to  designate  knives  that  are  about 
midway  in  length  between  Listen's  short  amputating  knife  and  the  ordinary 
straight  bistoury. 


Figure  SOI.    Metacarpal  Knife  (French  Pattern). 

The  Metacarpal  Knife,  designated  in  figure  901,  is  known  to  the  trade  as 
the  French  finger  knife.  It  does  not  differ  in  shape  of  blade  from  the 
long  straight  bistoury  described  on  page  276.  Its  usual  dimensions  are, 
width  of  blade  T7F  inch,  length  3^  and  total  length  of  knife  8^  inches. 

Cartilage  Knives. 

While  the  larger  scalpels,  shown  by  figures  591  to  597,  will  answer  in  the 
majority  of  cases,  the  surgeon  should  provide  himself  with  at  least  one 
knife  having  a  broad,  stout  and  somewhat  short  blade.  It  will  be  found 
useful  in  severing  cartilages  and  ligaments,  particularly  those  surrounding 
articulations. 


Figure  902.     Cartilage  Knife. 


The  Cartilage  Knife,  illustrated  by  figure  902,  possesses  all  the  qualifica- 
tions desirable  in  an  instrument  intended  for  cutting  through  cartilages, 
ligaments,  etc.  Its  blade  is  thick  and  heavy  and  is  strong  enough  to  meet 
all  requirements.  The  length  of  blade  is  3  and  its  total  length  7  inches. 


CHAPTER  XX. 


GUNSHOT  WOUND  SURGERY. 

Instruments  for  the  treatment  of  gunshot  may  be  divided  into  two 
classes,  those  for  location  and  those  for  removal  of  the  missile. 

LOCATION  OF  MISSILE. 

The  measures  adopted  to  locate  a  bullet  must  depend  largely  upon  its 
supposed  location  and  whether  it  is  lead  or  steel  cased.  For  the  former, 
ordinary  probes,  plain  or  porcelain  tipped,  will  serve  a  good  purpose,  but 
if  the  bullet  is  of  steel  or  steel  covered  and  deep  seated,  some  form  of 
electric  or  telephonic  searcher  is  preferable.  During  the  search  for  a 
missile,  if  the  perforated  limb  or  trunk  be  placed  in  the  same  position  as 
when  the  shot  was  received,  it  will  frequently  straighten  the  bullet  track 
and  assist  in  locating  the  missile.  All  instruments  inserted  into  the  track 
of  a  bullet  should  be  thoroughly  sterilized  before  use.  Instruments  for 
disclosing  the  location  of  a  bullet  may  be  classified  as  probes  and  trajectors. 

Probes. 

These  are  slender  bulb-pointed  instruments,  utilized  to  trace  or  follow  a 
bullet  track.  It  is  claimed  by  Senn  that  more  satisfactory  results  will  be 
obtained  in  the  use  of  the  probe,  if  its  rounded  end  be  of  the  same  size  as  or 
only  slightly  smaller  than  the  bullet  to  be  traced.  Probes  may  be  plain 
with  porcelain  head,  electric  or  telephonic. 

Plain  Probes. 

Hamilton's  Bullet  Probe,  as  shown  in  figure  903,  is  manufactured  from 
aluminum,  and  consists  of  a  slender  flexible  shaft,  terminating  at  one  end 
in  a  probe  point,  and  at  the  other  in  a  round  head  about  6  millimeters  in 


Figure  903.    Hamilton's  Bullet  Probe. 

diameter.     The  softness  of  the  metal  permits  it  to  be  curved  to  any  desired 
shape.     Its  length  is  4^  inches. 

Fluhrer's  Bullet  Probe,  as  delineated  in  figure  904,  consists  of  a  double 
ended  probe  12  inches  in  length,  made  from  a  single  piece  of  aluminum. 


Figure  934.    Fluhrer's  Bullet  Probe.    • 

The  shaft  is  somewhat  larger  in  the  center,  tapering  toward  each  end, 
where  it  terminates  in  bulbous  points  one  4,  the  other  6  millimeters  in 
diameter. 

402 

J&5JJ 


BULLET    PROBES.  403 

Probes  "with  Porcelain  Heads. 

These  are  constructed  with  a  roughened  porcelain  bulb  or  tip,  in  order 
that  when  rotated  or  otherwise  rubbed  against  a  leaden  bullet,  the  latter 
will  leave  a  dark  stain  upon  the  porcelain  head  at  the  point  of  contact.  In 


Figure  905.     N61aton's  Bullet  Probe. 

the  absence  of  such  a  probe,  the  surgeon  may  substitute  a  white  pine  stick 
smoothly  rounded  at  its  end. 

Kelaton's  Bullet  Probe,  as  described  in  figure  905,  consists  of  a  plain, 
flexible  rod,  with  handle,  to  which  is  attached  a  porcelain  head  generally 
from  5  to  10  millimeters  in  diameter.  The  usual  length  is  6  inches. 


O ' 

Figure  900.    Elastic  Bullet  Probe  with  Porcelain  Head. 

The  Elastic  Bullet  Probe,  exhibited  in  figure  906,  differs  from  the  pattern 
of  Nelaton,  principally  in  being  elastic,  the  better  to  follow  a  curved  or 
deflected  course.  Its  length  is  about  10  inches  and  the  diameter  of  the 
bulb  about  5  millimeters. 

Senn's  Bullet  Probe^  as  pictured  in  figure  907,  consists  of  a  soft  metal 
flexible  rod  jointed  in  the  center  and  tipped  at  either  end  with  a  porcelain 
head,  one  number  22  and  the  other  number  38,  French  scale.  Heretofore 
in  the  construction  of  probes  with  this  class  of  tips,  the  porcelain  portion 


Figure  907.    Senn's  Bullet  Probe. 

has  been  attached  to  the  rod  by  boring  or  moulding  a  hole  in  the  former 
and  fastening  the  two  parts  together  with  cement.  This  procedure  resulted 
in  many  accidents,  either  from  detachment  or  breaking  of  the  porcelain 
head.  After  much  experimenting,  a  probe  was  produced  with  an  opening 
entirely  through  the  porcelain  tip,  the  rod  passing  through  the  latter,  its 
distal  end  being  riveted  upon  the  outer  border  of  the  bulb.  This  method 
of  construction  renders  these  probes  perfectly  safe  without  in  the  least  im- 
pairing their  value.  The  full  length  of  this  probe  is  9  inches. 

Electric  Bullet  Probe. 

The  invention  of  reliable  dry  battery  cells  renders  it  possible  to  construct 
a  compact,  efficient  and  durable  electric  probe.  It  is  necessary  only  to 
include  a  single  cell  and  an  ordinary  Faradic  interrupter  in  a  small  case 
and  connect  the  cords  with  two  slender  insulated  metallic  probes,  both  of 
the  latter  included  in  a  small  canula.  The  probes  should  project  slightly 
beyond  the  distal  end  of  the  tube,  the  adjustment  being  such  that  by 
pressure  of  the  probes  against  a  metallic  substance,  the  electric  circuit  will 
be  completed,  and  will  be  indicated  by  the  buzzing  sound  produced  by  the 
passing  of  the  current  through  the  interrupter. 


404 


GUNSHOT  WOUND  SURGERY. 


The  Author's  Electric  Bullet  Probe,  shown  in  figure  908,  illustrates 
a  compact  electrical  appliance  for  locating  bullets.  Constructed  of  metal 
and  rubber  on  the  plan  above  indicated,  the  canula  and  contents  may  be 
thoroughly  disinfected.  When  in  use,  it  is  possible  to  contact  the  bullet 


Figure  908.    Author's  Electric  Bullet  Probe  for  Either  Leaden  or  Steel  Bullets. 

sought  without  completing  the  circuit;  for  if  only  one  probe  touch  the 
metallic  body  (as  upon  the  side)  the  circuit  is  not  complete.  In  such  cases 
the  operator  has  only  to  revolve  the  canula  and  at  some  one  point  on  the 
circuit  both  probes  will  engage  the  bullet. 

Telephonic  Probes. 

Girdner's  Telephonic  Probe,  as  illustrated  in  figure  909,  does  not  necessi- 
tate the  use  of  a  battery,  as  the  operating  current  is  taken  directly  from  the 
body  of  the  patient.  The  bulb  "  B, "  shown  in  the  illustration,  is  placed  in  the 
patient's  mouth,  while  the  probe  "A"  is  inserted  in  the  wound,  and  search 
for  the  bullet  made.  The  instrument  is  constructed  in  such  a  manner 


Figure  909.    Girdner's  Telephonic  Probe. 

that  if  brought  in  contact  with  a  metal  substance,  a  characteristic  clicking 
or  rattling  sound  is  produced  in  the  receiver,  which,  when  in  use,  is  held  in 
close  contact  with  the  ear  of  the  operator  (like  the  transmitter  of  an  ordinary 
telephone).  The  instrument  is  delicate,  and  when  once  understood,  will  be 
found  thoroughly  reliable.  When  in  use,  no  mistakes  need  be  made 
between  bone  and  metal. 


TRAJECTORS.  405 

Trajectors. 

These  are  employed  to  determine  the  approximate  location  of  a  bullet  in 
the  cranium.  The  principle  of  their  construction  is  best  shown  by  the 
following  illustration : 

Morgan's  Trajector,  as  traced  in  figure  910,  consists  of  a  solid  steel  bow, 
one  end  of  which  terminates  in  a  short  cylinder  of  tubing,  the  other  in  £, 
triangular  groove,  the  angle  of  the  latter  and  the  lumen  of  the  tube  having 
the  same  axis. 

The  instrument  is  intended  for  use  with  the  Fluhrer  probe,  as  shown  in 
figure  904.  The  latter  may  be  first  introduced  into  the  wound  following 


Figure  910.    Morgan's  Trajector. 

the  track  of  the  bullet  sought ;  when  passed  the  full  distance  of  the  track, 
the  steel  bow  may  be  placed  in  a  position  so  that  it  will  pass  over  or 
around  the  head,  the  triangular  groove  above  referred  to  resting  near  the 
skull,  on  the  surface  of ,  and  on  a  line  with,  the  probe.  The  small  terminal 
cylinder  above  referred  to,  is  provided  with  a  movable  rod  that  may  be  ex- 
tended back  and  forth  as  desired.  After  placing  the  bow  as  above  de- 
scribed, if  this  rod  be  pushed  forward,  it  will  rest  upon  the  scalp  at  the 
point  where  the  trephine  should  be  applied.  By  permitting  the  probe  to 
penetrate  to  the  full  extent  of  the  wound  and  locating  the  point  of  contact  of 
the  bow  with  the  probe  and  the  position  on  the  movable  rod  within  the 
cylinder  and  noting  the  relations  of  the  various  parts,  upon  removing  all  from 
the  head  and  replacing  them  as  marked,  the  depth  of  the  bullet  within  the 
skull  may  be  easily  determined. 


REMOVAL  OF  MISSILES. 

The  instruments  used  for  the  removal  of  gunshot  missiles  are  called 
forceps,  screw  extractors  and  scoops. 

Bullet  Forceps. 

Since  the  character  of  the  missiles  used  in  warfare  has  materially 
changed,  it  necessitates  new  forms  of  extractors.  In  days  when  bullets  were 
manufactured  wholly  from  lead,  it  was  possible  to  remove  them  by  the  aid 
of  forceps  with  short  jaws,  because,  with  even  a  slight  leverage,  it  was  easy 


406 


GUNSHOT  WOUND  SURGERY. 


with  such  an  instrument  to  penetrate  the  body  of  the  bullet,  thus  establish- 
ing a  grip  sufficiently  firm  for  its  removal. 

Such  instruments  are,  however,  practically  worthless  when  an  attempt  is 
made  to  extract  a  steel-encased  missile.  The  rounded  form  of  the  latter 
receives  only  a  glancing  force  when  grasped  by  the  jaws  of  the  ordinary 
bullet  forceps.  It  is  evident  that  forceps  with  concave,  serrated  jaws 


Figure  911.    Senn's  Bullet  Forceps  for  Steel  or  Steel-Encased  Bullets. 

would  answer  in    such    cases,    provided  the  internal  measurements  were 
exactly  the  size  of  the  external  diameter  of  the  bullet. 

To  use  efficiently  this  form  of  forceps  would  necessitate  employing 
several  instruments  and  a  previous  knowledge  of  the  exact  size  of  the 
bullet  sought.  An  efficient  instrument  must  be  one  that  will  firmly  grasp 
any  size  of  bullet.  This  can  best  be  accomplished  by  forceps  with  con- 


Figure  912.    Gross'  Fenestrated  Bullet  Forceps. 

cave  jaws,  the  terminal  margins  of  which  are  provided  with  short,  strong 
teeth,  sharpened  to  a  fine  point.  A  third  shorter  and  stouter  tooth,  inter- 
posed between  the  two  lateral  teeth,  would  form  in  each  jaw  a  third  point  of 
contact  in  case  of  smaller  bullets. 

Senn's  Bullet  Forceps,  as  presented  in  figure  911,  are  constructed  of 
such  size  that  the  jaws,  when  closed,  are  the  size  of  a  number  38  bullet  and 
of  as  nearly  the  same  shape  as  it  is  possible  to  make  them.  This  instrument, 


Figure  913.    Thomasin's  Bullet  Forceps. 

unless  introduced  into  a  tortuous  track  or  in  cases  where  a  bullet  has  been 
deflected  into  the  denser  tissues,  will  answer  every  purpose  of  a  probe,  and 
if  brought  in  contact  with  the  bullet,  would,  under  ordinary  circumstances, 
furnish  a  grip  of  sufficient  strength  to  dislodge  and  withdraw  it. 

Gross' Bullet  Forceps,  as  sketched  in  figure  912,  differ  from  those  last 
before  described  only  in  the  shape  of  the  jaws,  which  in  this  instance  are 
fenestrated  the  better  to  accommodate  the  instrument  to  various  sizes  of 
bullets.  In  order  that  the  operator  may  secure  a  firm  hold,  the  inner 
surfaces  of  the  loops  forming  the  fenestrse  are  serrated  or  roughened.  They 


EXTRACTORS SCOOPS. 


407 


possess  an  advantage  over  the  pattern  before  described  in  that  it  may  be 
serviceable  in  the  extraction  of  a  steel  covered  bullet. 

Thomasin's  Bullet  Forceps,  as  shown  in  figure  913,15  the  oldest  pattern 
in  use.  According  to  Gross,  this  instrument  was  devised  in  the  latter  part 
of  the  1 8th  century.  It  is  quite  slender  in  its  blades,  both  of  which 
terminate  in  short,  stout  tooth-like  points,  the  object  of  which  is  to  grasp 
any  portion  of  the  contacted  bullet  by  forcibly  embedding  the  teeth  or 
prongs  into  the  body  of  the  missile.  It  is  adapted  only  for  leaden  bullets. 
Its  usual  length  is  9^  inches. 

Screw  Extractors. 

These  differ  from  bullet-penetrating  forceps  as  they  have  a  sharp-pointed 
projection  operated  by  screw  power  for  penetrating  and  extracting  the  mis- 
sile. We  illustrate  two  patterns,  one  for  the  removal  of  shot,  the  other 
adapted  for  withdrawing  a  leaden  bullet  when  firmly  imbedded  in  bone  or 
other  solid  tissue. 

Thomasin's  Shot  Extractor,  as  represented  in  figure  914,  consists  of  a 


Figure  914.    Thomasin's  Shot  Extractor. 


slender  steel  tube  enclosing  a  sharp-pointed  stylet  operated  by  screw  power. 
The  tube  terminates  in  a  curved  projection,  shaped  to  embrace  the  farthest 
extremity  of  the  missile.  After  being  passed  around  or  beyond  the  shot, 
the  latter  may  be  pierced  by  the  stylet,  after  which  it  may  be  safely  re- 
moved. 

Collins'  Bullet  Extractor,  as  evidenced  in  figure  915,  consists  of  two  can- 


Figure  915.    Collins'  Bullet  Extractor. 

ulas,  each  terminating  in  sharply  cut  teeth  employed  to  assist  in  securing  a 
firm  grasp  upon  the  bullet  to  be  removed.  Within  the  canula  a  stylet  is 
operated  by  a  threaded  screw.  The  latter  is  used  to  pierce  the  bullet,  and 
for  this  purpose  terminates  in  a  gimlet  point.  When  in  use,  the  canula  and 
stylet  should  be  pressed  firmly  against  the  bullet  and  the  latter  turned  or 
twisted  until  a  firm  grasp  is  secured. 

Scoops. 

These  consist  of  spoon-shaped  instruments  used  for  dislodging  and  re- 
moving bullets. 


Figure  016.     Bullet  Scoop. 


The  Bullet  Scoop,  shown  by  figure  916,  consists  of  a  small,  ladle-shaped 
instrument  formed  in  the  distal  end  of  a  slender  shank,  the  latter  attached 
to  a  handle.  The  rim  of  the  scoop  is  usually  oval  in  form,  the  outer  border 
projecting  upward  in  the  form  of  a  lip. 


CHAPTER  XXI. 


OPERATING  AND  POCKET  CASES. 

The  question  of  how  best  to  construct  cases  for  the  transportation  of  sur- 
gical instruments  has  occupied  the  mind  of  surgeons  and  instrument  makers 
probably  since  the  earliest  history  of  medicine.  For  many  years,  major 
operating  sets  were  encased  in  fancy  boxes  of  hardwood,  each  instrument 
embedded  in  the  body  of  the  case  by  carving  out  a  space  into  which  the  in- 
strument would  accurately  fit,  the  whole  interior  surface  being  covered  with 
velvet  or  other  soft  fabric,  as  exhibited  in  figure  917.  Such  cases,  when 
they  contained  a  large  number  of  instruments,  were  often  constructed  with 
inner  trays  which,  by  increasing  the  surface  space,  provided  ample  room 
for  all. 

That  these  cases  furnished  fertile  fields  for  the  propagation  of  bacteria 
there  is  no  question.  The  advent  of  aseptic  surgery  required  something 
more  cleanly  and  the  velvet  was,  in  many  instances,  replaced  by  a  leather 
lining.  This  was  followed  by  an  omission  of  all  linings,  the  space  carved 
out  of  the  wood  for  the  instruments  being  polished,  and  the  case  of  such 
material  that  it  might  be  sponged  out  or  otherwise  cleansed  with  antiseptic 
solutions.  This  form  of  case,  however,  soon  gave  way  to  those  constructed 


Figure  917.  Showing  Old-Style  Velvet-lined  Case.  Figure  918.    Showing  All-metal  Case. 

entirely  of  metal,  as  traced  in  figure  918,  in  which  loops,  hooks  and  cross- 
bars were  employed  to  securely  hold  the  instruments  upon  metallic  plates. 
This  marked  a  great  advance,  the  only  objection  offered  being  the  difficulty 
on  the  part  of  the  surgeon  in  relocating  an  instrument  after  it  had  been 
removed  from  the  case. 

This  disadvantage  has  been  overcome,  and  such  expensive  construction 
rendered  unnecessary  since  it  has  been  demonstrated  that  instruments  may 
be  safely  transported  in  washable  roll-up  pouches,  each  article  being  held 
in  place  by  non-elastic  loops.  This  plan  forms  an  ideal  method,  for  not 
only  may  changes  be  made  in  the  instruments  making  up  the  set  by  discard- 
ing any  that  may  be  deemed  unnecessary,  but  new  patterns  may  be 
added  from  time  to  time.  If  desirable,  the  surgeon  may  provide  himself 
with  two  of  the  cloth  rolls,  that  one  may  be  kept  in  reserve,  properly  steril- 
ized, and  ready  for  changing  at  any  time.  These  roll-up  pouches  may  be 
included  in  metallic  telescoping  trays  that  may  be  used  as  instrument  ster- 

408 


OPERATING  CASES. 

ilizers,  thus  furnishing  all  that  is  really  necessary  in  the  way  of  instrumental 
equipment. 

If  the  future  is  to  be  judged  by  the  past,  these  forms  of  cases  will,  in 
turn,  give  way  to  some  style  that  will  be  an  improvement  upon  the  pat- 
terns here  illustrated.  At  present,  however,  they  seem  to  form  an  ideal 
method,  and  we  believe  that  surgeons,  generally,  will  be  benefited  if  they 
abandon  cases,  whether  minor  or  major,  in  which  the  instruments  are  each 
contained  in  special-shaped  recesses  or  in  which  there  is  no  provision  for 
additional  instruments. 

Operating-  Cases. 

Terry's  Modification  of  Senn's  Minor  Operating  Case,  as  defined  in 
figure  919,  contains  all  that  is  deemed  essential  for  emergency  use.  The 
instruments,  inclusive  of  needles,  are  thirty-two  in  number  and  are  included 
in  a  washable  roll-up  pouch.  This  is  protected  by  two  telescoping  trays, 
either  of  which  may  be  used  for  sterilizing  purposes.  The  smaller  or  lower 
tray  is  provided  with  folding  legs  and  handles  so  that  it  may  be  employed 


Showing1  the  Various  Parts  of  Terry's-Senti's  Operating  Case. 


***  / 


Figure  919.    Instrument  Roll  of  Terry's-Senn's  Operating  Case. 

as  a  sterilizing  boiler.  The  whole  is  covered  by  a  patent  leather  pouch 
with  strap  for  carrying  over  the  shoulder.  In  detail,  the  assortment  of 
instruments  is  as  follows: — 

Large  scalpel,  figure  552. 

Small  scalpel,  figure  555. 

Straight  bistoury,  figure  561. 


410  OPERATING    AND    POCKET    CASES. 

Curved  sharp-point  bistoury,  figure  576. 

Tenotome,  figure  588. 

Tenaculum,  figure  581. 

Exploring  trocar,  figure  90. 

3  Pean's  hemostatic  forceps,  figure  648. 

3  Tait's  hemostatic  forceps,  figure  650. 

3  Kocher's  hemostatic  forceps,  figure  658. 

1  pair  Senn's  bullet  probes,  figure  907. 
Straight  scissors,  figure  631. 
Curved-on-the-flat  scissors,  figure  635. 
Bone  gouge,  figure  812. 

Ferguson's  scoop  and  periosteotome,  figure  848. 

2  Ferguson's  retractors,  guarded,  figure  622. 
Senn's  saw  with  guard  for  blade. 

McLean's  amputating  knife  with  folding  handle. 

Bone  forceps  with  spring,  figure  850. 

Dressing  forceps,  figure  608. 

Senn's  bullet  forceps,  figure  911. 

Pair  probes,  figure  636. 

Ligature  carrier  and  director,  figure  679. 

Coil  silver  wire. 

2  skeins  braided  silk,  assorted. 

i  dozen  silkworm  gut  sutures. 

y2  dozen  needles  for  intestinal  sutures. 

i  dozen  surgical  needles,  assorted. 

The  six  knives  are  included  in  two  protecting  plates,  as  shown  in 
figure  3.  These  rest  side  by  side  and  form  one  fold  of  the  case.  The  roll- 
up  pouch  is  made  of  light  duck,  while  the  edges  of  the  flaps  and  the  loops 
are  of  tape  firmly  stitched  in  place. 

Opposite  each  loop  the  name  of  the  instrument  occupying  that  particu- 
lar space  is  stamped  with  indelible  ink,  that  the  instruments  may  be 
returned  to  their  proper  positions  after  being  taken  from  the  roll.  When 
folded  flat  and  placed  within  the  telescoping  boxes,  the  whole  occupies  a 
space  8  inches  in  length  by  4^  in  breadth  and  2^  in  thickness. 

Terry's  Major  Operating  Set,  as  pictured  in  figure  920,  includes  the 
instruments  now  deemed  necessary  in  modern  surgical  practice.  The  outfit 
was  designed  particularly  for  the  use  of  the  National  Guard  in  the  Hispano- 
American  war.  It  was  the  result  of  an  effort  to  secure  in  a  compact  form 
an  assortment  of  instruments  that  might  be  contained  in  a  roll-up  pouch 
enclosed  within  metallic  boxes  that  could  be  utilized  as  a  sterilizer.  The 
outfit  consists  of  the  following : — 

Long  amputating  knife,  figure  897. 

Medium  amputating  knife,  figure  897. 

Short  catlin,  figure  900. 

Long  French  finger  knife,  figure  901. 

Heavy  cartilage  knife,  figure  902. 

Large  scalpel,  figure  552. 

Medium  scalpel,  figure  555. 

Straight  bistoury,  figure  561. 

Curved  sharp-point  bistoury,  figure  576. 

Curved  probe-point  bistoury,  figure  5  74. 

Tenotome,  figure  588. 

Tenaculum,  figure  581. 


OPERATING    CASES. 

Aneurysm  ligature  carrier,  figure  580. 
Amputation  saw,  figure  833. 
Metacarpal  saw,  figure  830. 

2  Retractors,  figure  622. 
Straight  bone  forceps,  figure  850. 
Angular  bent  bone  forceps,  figure  852. 
Bone  gouging  forceps,  curved,  figure  859. 
Bone  sequestrum  forceps,  figure  867. 

3  Tait's  hemostatic  forceps,  figure  650. 

3  Kocher's  hemostatic  forceps,  figure  658. 
3  Pean's  hemostatic  forceps,  figure  648. 


411 


Showing  the  Various  Parts  of  Terry's  Major  Operating  Case. 


Figure  920.    Terry's  Major  Operating  Set. 

Lead  mallet,  figure  828. 
Bone  chisel,  figure  810. 
Bone  gouge,  figure  812. 
Bone  scoop  and  elevator,  figure  848. 
Devilbiss  cranial  gouging  forceps,  figure  890. 
Devilbiss  trephine,  figure  889. 
Volkmann's  bone  scoop,  figure  804. 
Periosteal  elevator  and  raspatory,  figure  891. 


412 


OPERATING    AND    POCKET    CASES. 


Straight  scissors,  figure  631. 
Curved-on-the-flat  scissors,  figure  635. 

1  Set  Murphy's  buttons,  figure  969. 
Senn's  bullet  forceps,  figure  911. 
Senn's  bullet  probe,  figure  907. 
Pair  of  silver  probes,  figure  636. 
Needle-holding  forceps,  figure  756. 

2  needle  cases  containing  needles,   silk,   silkworm  gut,  silver  wire  and 
plastic  pins. 


-Figure  921.    Old-Style  Leather  Pocket  Case. 


Figure  922.    All-metal  Pocket  Case. 


The  large  knives  and  bistouries  are  protected  by  guards  similar  to  those 
shown  in  figure  3.  They  are  so  arranged  that  each  is  firmly  held  in  place 
and  are  so  protected  that  they  will  not  be  injured  by  other  instruments.  The 
Murphy  buttons  are  included  in  a  small  metallic  box,  while  the  needles  and 
sutures  are  contained  within  two  flat  oval  boxes  held  in  place  by  loops. 


Figure  921    Author's  Small  Pocket  Case. 


These  instruments  are  arranged  in  two  roll- up  pouches,  each  with  non- 
elastic  loops  and  of  such  construction  that  they  may  be  washed  and  sterilized. 
They  are  contained  within  two  telescoping  boxes,  either  of  which  may  be 
utilized  as  a  sterilizer.  One  of  these,  the  deeper,  is  supplied  with  a  remov- 


POCKET     CASES. 


413 


able  tray  with  handles,  folding  legs  and  perforated  bottom,  thus  supplying 
all  the  requisites  of  an  instrument  boiler.  This  outfit,  with  sterilized  water 
and  the  specially  prepared  dressings  exhibited  by  figures  792  and  794,  will 
enable  the  surgeon  to  perform  an  operation  under  strict  aseptic  technique. 
The  whole  outfit  may  be  included  in  a  heavy  leather  cover. 

Pocket  Oases. 

Pocket  Cases  were  formerly  made  of  leather  with  velvet  linings,  as  pic- 
tured in  figure  921.  In  earlier  years  they  were  large  and  bulky,  usually 
in  three  or  four  folds,  no  effort  being  made  to  construct  them  in  compact 
form.  Knives  with  shell  or  rubber  handles  were  in  universal  use,  and 
instruments  generally  were  of  unwieldy  patterns.  These,  in  more  mod- 
ern times,  gave  way  to  cases  with  leather  lining,  some  of  which  were  for 
use  with  solid-handle  knives,  those  made  from  one  piece  of  steel.  In  these 
cases  protection  for  the  blades  was  sometimes  provided  by  metal  plates  or 
layers  of  cork.  Simultaneously  with  the  latter,  cases  of  all  metal,  as 
sketched  in  figure  922,  were  constructed,  and  at  this  time  the  latter  pattern 
forms  the  standard  case  in  the  hands  of  the  more  progressive  surgeons. 

The  Pocket  Case  exhibited  in  figure  923  is  intended  to  present  a  limited 
number  of  instruments  deemed  most  available  for  emergency  use.  Those 
selected  consist  of 

Dressing  forceps,  figure  608. 

Straight  scissors,  figure  631. 

Kocher's  artery  forceps,  figure  658. 

Ear  spoon  and  hook,  figure  1781. 

Ligature  carrier  and  director,  figure  679. 


Figure  924.    Author's  Large  Pocket  Case. 

Pair  of  silver  probes,  figure  636. 
Scalpel,  figure  553. 

Sharp  point  curved  bistoury,  figure  576. 
Tenotome,  figure  589. 
Tenaculum,  figure  581. 
Needles  and  silk. 

These  are  included  in  a  small,  stiff  cloth  case  of  such  construction  that  it 
may  be  sterilized  by  boiling.      The  surgeon  may  provide  himself  with  an 


414  OPERATING    AND    POCKET    CASES. 

extra  case,  that  one  may  be  available  while  the  other  is  being  cleansed. 
For  transportation  this  is  included  in  a  small  metal  case  of  firm  construction. 

The  Large  Pocket  Case  pictured  in  figure  924  differs  from  the  pattern 
previously  described  in  containing  a  larger  number  of  instruments.  The 
latter  consist  of 

Scissors,  figure  631. 

2  Kocher's  artery  forceps,  figure  658. 

Dressing  forceps,  figure  608. 

2  Slide-catch  tissue  and  torsion  forceps,  figure  606. 

2  Serresfins,  figure  671. 

Male  and  female  catheter,  figure  1268. 

Exploring  needle,  figure  89. 

Scoop  and  elevator,  figure  809 A. 

Ear  spoon  and  hook,  figure  1781. 

Grooved  director  and  ligature  carrier,  figure  679. 

Pair  probes,  figure  636. 

Scalpel,  figure  553. 

Curved  sharp-point  bistoury,  figure  576. 

Curved  probe-point  bistoury,  figure  574. 

Straight  bistoury,  figure  561. 

Tenotome,  figure  589. 

Tenaculum,  figure  581. 

Needles  and  silk. 


CHAPTER  XXII. 


LAPAROTOMY. 

Under  this  heading  we  will  include  a  description  of  instruments  nec- 
essary for  abdominal  section.  The  list  will  embrace  appliances  for  opera- 
tions on  the  appendix,  intestines,  stomach,  pancreas,  spleen,  biliary  ducts, 
abdominal  gunshot  wounds,  etc.,  excluding  operations  on  the  bladder  and 
female  generative  and  genito-urinary  organs.  The  following  are  required : 

Minor  operating  instruments  described  on  pages  270  to  275; 

Scissors,  short  and  angular,  for  enlarging  primary  incision ; 

Scissors,  long  and  straight,  for  deep  incisions ; 

Scissors,  long  and  curved  on  the  flat,  for  deep  incisions ; 

Scissors,  long  and  angular,  bent  on  the  edge,  also  for  deep  incisions; 

Abdominal  retractors  for  enlarging  the  field  of  vision ; 

Flat  sponges  for  protecting  abdominal  viscera,  absorbing  fluids,  etc. ; 

Sponge  holders; 

Long  compression  forceps  for  deep  hemostasis ; 

Volsellum  forceps  for  manipulating  tumors,  organs,  etc. ; 

Long  dressing  or  packing  forceps  for  applications,  etc. ; 

Long  tenacula  for  holding  or  raising  tissues ; 

Long  tissue  forceps  for  holding  tissues  during  excision ; 

Needles  for  intra-peritoneal  sutures ; 

Needles  for  closing  abdominal  wound ; 

Drainage  tubes; 

Abdominal  binder; 

Truss  for  patient  on  getting  up  after  an  operation  for  appendicitis. 
Intestinal  Operations  .and  those  involving  anastomosis  may  require : 

Buttons  or  couplers  for  joining  the  severed  parts,  and 

Forceps  for  introduction  of  same ;  or, 

Plates  for  providing  a  firm  base  for  suturing ; 

Clamps  for  closing  the  intestinal  lumen ; 

Needles  for  intestinal  sutures,  and 

Forceps  for  clamping  severed  parts  together  while  being  sutured. 

Abdominal  "Wall  Scissors. 

Scissors  angular  bent  or  curved  on  the  edge  are  required  for  enlarging 
the  abdominal  incision,  and  for  this  purpose  should  be  constructed  with  the 
lower  blade  well  rounded  or  probe-pointed.  Straight  scissors  may  be 
utilized  for  this  purpose,  but  are  not  so  satisfactory.  If  sharp-pointed 
scissors  are  employed,  the  lower  blade  should  be  guided  by  a  director. 
When  in  use,  scissors  for  this  purpose  may  be  guarded  by  one  or  two 
fingers  placed  within  the  abdominal  cavity  and  resting  against  the  tissues 

415 


416 


LAPAROTOMY. 


to  be  incised.     Such  scissors  may  also  be  employed  for  dividing  the  cervix, 
contracting  vaginal  bands,  or  for  operations  on  fistulas. 

Byford's  Abdominal  Wall  Scissors,  as  displayed   by  figure    925,  are   of 
light  construction,  angular  in  form  and  about  6  inches  in  length.     The 


Figure  935.     Byford's  Abdominal  Wall  Scissors. 

lower  blade  is  elongated  and  probe-pointed,  so  as  to  facilitate  its  passage 
between  different  layers  of  tissues. 

Leslie's  Abdominal  Wall  Scissors,  as  sketched  for  figure  926,  are  con- 
structed with  rounded  and  somewhat  probe-pointed  blades,  which  may  not 
only  be  utilized  for  increasing  the  size  of  the  wound  opening,  but  are  also 


Figure  936.    Leslie's  Abdominal  Wall  Scissors. 

useful  for  dividing  layers  of  fascia  in  many  other  operations.  The  lower 
and  round-pointed  blade  extends  slightly  beyond  the  upper  and  heavier 
one,  thus  facilitating  its  passage  between  tissue  layers,  its  shape  preventing 
penetration  of  surrounding  parts  and  consequent  injury  to  vessels.  A 
desirable  length  is  from  5  ^  to  6  inches. 

Intra- Abdominal  Scissors. 

Scissors  for  intra-abdominal  surgery  differ  from  ordinary  patterns  in 
being  constructed  with  longer  handles  that  not  only  afford  greater  leverage, 
but  also  enable  the  surgeon  to  make  incisions  deeply  within  the  abdominal 
cavity. 

Sims'  Straight  Scissors  are  the  ordinary  pattern  of  uterine  or  intra- 
abdominal  scissors.  As  illustrated  by  figure  927,  they  may  be  obtained 


Figure  937.    Sims'  Straight  Scissors. 

with  both  points  round,  both  points  sharp,  or  with  one  round  and  one 
sharp  point,  the  latter  affording  the  best  combination.  The  usual  lengths 
are  8  and  8^  inches,  a  7^  and  9  inch  pattern  being  occasionally  preferred. 
Sims'  Curved  Scissors  differ  from  those  last  described  in  being  curved  on 
the  flat.  They  are  employed  for  severing  pedicles,  for  removing  tumors 


ABDOMINAL    RETRACTORS. 


and  in  intra-abdominal  incisions  not  on  a  line  with  the  scissors  handle. 
They  may  be  procured  with  both  points  rounded,  as  outlined  by  figure  928, 
both  points  sharp,  or  with  one  round  and  one  sharp  point.  For 
abdominal  surgery  the  usual  length  is  either  8  or  8^  inches,  a  7^  and 
9  inch  pattern  being  occasionally  employed. 


Figure  928.    Sims'  Curved  on  the  Flat  Scissors. 


Scissors  of  Angular  or  Knee  Bent  Patterns,  as  detailed  by  figure  929,  may 
be  employed  to  advantage  in  many  intra-abdominal  and  intra-vaginal 
operations.  They  may  be  utilized  for  severing  deep-seated  tissues,  forming 
an  artificial  fistula,  dividing  the  cervix,  etc.  Usually  they  may  be  obtained 
with  one  or  both  points  blunt  or  rounded,  and  in  lengths  of  from  7^  to  8^ 
inches. 


Figure  929.    Angular  or  Knee  Bent  Scissors. 

Abdominal  Retractors. 

These  differ  from  the  patterns  described  on  page  284  only  in  being 
broader  and  provided  with  retracting  surfaces  of  sufficient  depth  to  include 
in  its  grasp  the  entire  thickness  of  the  abdominal  wall. 

In  the  absence  of  retractors  with  short  blades,  in  patients  with  thin 
abdominal  walls,  two  volsellum  forceps  may  be  employed  to  advantage. 
With  them  the  entire  wall,  including  the  peritoneum,  may  be  grasped  and 
everted  or  turned  outward,  after  which  the  handles  of  the  forceps 
furnish  a  good  grasping  surface  for  continued  use. 


Figure  930.     Lange's  Retractor. 


Lange's  Retractor  is  perhaps  the  lightest  and  yet  the  strongest  of 
this  class  of  instruments.  When  properly  made,  it  is  constructed  of  steel 
with  thin  blades,  thus  furnishing  the  greatest  amount  of  retracting  strength 
with  the  least  possible  sacrifice  of  operating  space. 

As  defined  by  figure  930,  they  are  of  two  sizes,  that  they  may  be 
nested  when  packed  for  transportation.  This  feature  renders  them  desir- 
able for  service  out  of  the  hospital.  The  blade  of  the  smaller  one  is 

27 


418 


LAPAROTOMY. 


i/%  inch  wide  and  i5/s  inches  in  depth,  with  a  total  length  of  8^4  inches. 
The  larger,  which  is  usually  employed,  is  i3/%  inches  in  width  and  2^ 
inches  in  depth,  with  a  total  length  of  9^  inches. 

Halsted's  Retractors  are   constructed    with    well-roiinded  contact   faces 
and  supplied  with  handles  with  finger  depressions  to  afford  good  gripping 


Figure  931.     Halsted's  Retractors. 

surfaces.  They  are  well  depicted  by  figure  931.  The  smallest  retractor  is 
i5/8  inches  in  width  and  2^  inches  in  depth,  with  .an  extreme  length  of  8^£ 
inches.  The  second  in  size  is  2  inches  in  width,  2*4  inches  in  depth, 
with  a  total  length  of  8%"  inches.  The  next  larger  is  3^  inches  in 
width,  2^4  inches  in  depth,  with  an  extreme  length  of  9^  inches,  while  the 


Figure  932.    Eastman's  Retractor. 

largest  is  3^  inches  in  width,  3  inches  in  depth,  with  a  length  of  9^  inches. 

Eastman's  Retractor  is  one  of  the  broadest  and  heaviest  of  this  class  of 

instruments,   the  blade  presenting  a  convex  retracting  surface  about  zy2 

inches  in  width  by  3  inches  in  length.     The  inner  or  lower  extremity  of 


Figure  933.    Owens'  Retractor. 


the  blade  is  flanged  and  projects  slightly  backward,  that  the  applied  power 
may  not  tend  to  force  the  instrument  out  of  the  abdominal  opening.  The 
length  of  shank  is  about  7  inches,  the  proximal  end  being  curved  to  afford 
a  firm  grip.  The  instrument  is  pictured  by  figure  932. 


SPONGES.  419 

Owens'  Retractor,  as  will  be  seen  by  figure  933,  is  supplied  in  two  sizes, 
the  smaller  furnishing  a  retracting  surface  2^  inches  wide,  with  a  length  of 
8^  inches,  the  larger  differing  only  in  the  spread  of  the  blades,  which  is 
increased  to  3  inches.  The  peculiar  curve  of  the  shank  enables  the 
assistant  to  hold  it  with  greater  ease  than  most  other  patterns.  The  handle 
is  of  sufficient  size  to  comfortably  fill  the  hand,  while  the  bend  of  the  shank, 
as  compared  with  the  handle,  is  at  such  an  angle  that  the  hand  does  not 
become  tired  even  after  long  continued  use.  This  instrument  furnishes 


Figure  934.    Plan's  Abdominal  Retractor. 

means  for  exerting  a  large  amount  of  traction  force,  with  the  outlay  of  a 
minimum  quantity  of  muscular  strength,  and  for  this  reason  should  be- 
come popular. 

Pean's  Abdominal  Retractors,  as  portrayed  in  figure  934,  consist  of  long- 
blades,  with  handles  attached  in  trowel  form.  These  blades  are  concave 
along  what  might  be  termed  the  under  surface  of  the  trowel,  and  are  bent 
outward  at  an  angle  of  about  25°.  They  are  not  only  employed  as  ordinary 
retractors,  but  for  holding  back  the  deeper  layers  of  the  abdominal  viscera. 
They  are  of  different  sizes,  varying  from  1 5^  to  i  ^  inches  in  breadth  and 
from  5  to  6^  inches  in  length  of  blade. 

Spong-es. 

Flat  sponges  or  substitutes  are  employed  in  the  abdominal  cavity  dur- 
ing operations.  They  are  used  as  packing,  to  prevent  the  closing  or 
obstruction  of  the  operating  field  by  the  intrusion  of  the  viscera,  as 
coverings  to  prevent  tissue  injury,  and  as  absorbents  to  take  up  and  retain 
extravasated  blood  and  other  liquids.  Those  of  large  size  are  usually 
selected,  that  the  number  may  be  limited,  as  a  guard  against  the  accidental 
non-removal  of  one  or  more  before  closure.  As  a  matter  of  precaution, 
where  sea  sponges  are  employed  in  the  abdominal  cavity,  it  has  been 
advised  that  each  be  clamped  at  its  outer  margin  with  a  heavy  hemostatic 
forceps,  the  latter  being  allowed  to  protrude  from  the  wound. 

Owing  to  the  difficulties  attending  the  perfect  sterilization  of  sponges, 
they  have  been  replaced  by  many  surgeons  with  pads,  made  from  several 
thicknesses  of  antiseptic  gauze,  in  many  cases  supplied  with  tapes  firmly 
attached,  the  free  ends  of  the  latter  being  allowed  to  protrude  from  the 
wound  where  they  are  clamped  by  compression  forceps.  If  large  sponges 
are  used,  a  better  protection  for  the  viscera  is  secured,  and  the  dangers  of 
accidental  loss  diminished. 

Flat  Sponges  for  abdominal  use,  as  illustrated  in  figure  686,  are  generally 
from  y<z  to  i  inch  in  thickness  and  from  3  to  6  inches  in  diameter.  Two  or 
three  sizes  should  be  provided,  some  for  covering  extensive  surfaces  and 
others  for  packing  into  small  spaces. 

Artificial  Sponges,  as  shown  by  figure  689,  are  usually  constructed  from 
several  thicknesses  of  antiseptic  gauze,  the  edges  being  carefully  turned  in 
and  the  whole  stitched  together. 


420 


LAPAROTOMY. 

Sponge   Holders. 


Sponge  holders,  previously  described  by  figures  690  to  692,  may  be  either 
in  rod  form  as  there  shown  or  of  the  forceps  pattern  as  exhibited  in  the 
following  illustrations : 

Emmet's  Sponge  Holding  Forceps,  as  shown  in  figure  935,  is  a  slender 
scissors  handle  pattern  8^  inches  in  length,  with  a  ratchet  catch. 


Figure  935.    Einmet's  Sponge  Holding  Forceps. 


The  distinguishing  feature  is  the  peculiar  shape  of  the  teeth,  which,  with 
the  exception  of  the  two  in  the  terminal  ends  of  the  blades,  are  formed  by 
four  pins  projecting  inward  from  the  jaw  surfaces;  two  of  these  are  upon 
either  side  facing  each  other  and  so  situated  that  when  the  forceps  are 
closed,  all  are  equidistant  from  each  other.  A  sponge  placed  within  the 


Figure  93C.     Byford's  Sponge  Holding  Forceps 


grasp  of  these  forceps  is  thus  clasped    at  five  points;  a  good  guarantee 
against  its  being  accidentally  loosened. 

Byford's  Sponge  Holding  Forceps  are  among  the  longest  of  this  class  of 
instruments.  They  are  usually  n  inches  in  length,  each  blade  terminating 
in  a  sharp  tenaculum-shaped  tooth,  so  adjusted  that  when  the  blades  are 


Figure  937.    Wilson's  Sponge  Holding  and  Dressing  Forceps. 

closed  they  form  a  loop,  thus  encircling  that  portion  of  the  sponge  included 
in  their  grasp.     Their  characteristics  are  explained  by  figure  936. 

Wilson's  Sponge  Holding  Forceps,  as  indicated  by  figure  937,  differ  from 
the  pattern  commonly  in  use  in  being  heavier  and  presenting  a  larger  con- 
tact surface.  The  jaws  are  fenestrated  with  fine,  well-rounded  margins,  from 
which  a  sponge  can  not  be  easily  torn  nor  loosened.  It  may  be  employed  for 
the  insertion  of  packing  and  for  general  dressing  purposes. 


COMPRESSION  FORCEPS. 


Compression  Forceps. 


421 


Compression  forceps  differ  from  the  patterns  employed  in  minor  oper- 
ating surgery  only  in  being  longer  and  heavier.  Forceps  for  general  use  in 
arresting  hemorrhage  are  usually  applied  to  wounds  within  range  of  the  field 
of  vision  where  it  is  not  necessary  to  involve  much,  if  any  tissue  other  than 
the  bleeding  vessel.  In  abdominal  surgery  it  is  often  necessary  to  arrest 
hemorrhage  from  vessels  not  only  deep-seated,  so  that  the  exact  point  of 
injury  can  not  be  located,  but  at  times  to  compress  large  masses  of  tissue 
before  hemostasis  is  secured. 

Forceps  for  this  purpose,  therefore,  should  be  from  6  to  8  inches  in 
length,  possess  a  large  compressing  surface,  and  be  provided  with  several 


Figure  938.    P6an's  Straight  Compression  Forceps. 


Figure  939.    Plan's  Compression  Forceps,  Curved  on  the 


Figure  940.    Plan's  Compression  Forceps,  Curved  on  the  Edge 


catches  that  not  only  afford  a  safe  grasp,  but  that  will  enable  the  forceps 
to  accommodate  different  thicknesses  of  tissue. 

Pean's  Compression  Forceps  are  of  three  patterns:  The  first,  figure 
938,  exhibits  a  straight  form  that  may  be  obtained  in  three  lengths,  8,  9^ 
and  ii  inches.  Figure  939  is  of  similar  construction,  8  inches  in  length 
but  curved  on  the  flat,  while  figure  940  differs  from  the  second  only  in 
being  curved  on  the  edge.  All  should  be  constructed  of  steel,  somewhat 
light  in  weight,  finely  tempered  and  the  blades  so  shaped  that  when 
pressure  at  the  tip  is  secured,  a  considerable  space  will  exist  between  the 
jaws  of  the  forceps  throughout  nearly  their  entire  length.  If  properly 
made,  the  spring  of  these  blades  when  tightly  closed  will  furnish  an  almost 


422 


LAPAROTOMY. 


uniform  pressure  at  all  points  of  the  jaw.  This  principle,  shown  by  figure 
646,  is  desirable  in  all  forceps  of  this  character,  as  they  are  safer  and  more 
certain  in  their  results. 

Etheridge's   Compression  Forceps,  as  shown  by  figure  941,  are  of  heavy 
construction,  8  inches  in  length,  with  blades  the  crushing  surface  of  which 


Figure  941.    Etheridge's  Compression  Forceps 


is  2%  inches  long.  Like  the  patterns  of  Pean  last  described  they  are  de- 
signed to  enable  the  operator  to  receive  the  benefit  of  the  spring  force  of  a 
long  and  slightly-curved  jaw. 


Figure  942.    Ferguson's  Compression  Forceps. 

Ferguson's  Compression  Forceps,  as  shown  in  figure  942,  are  fully  de- 
scribed under  figure  654.  As  they  are  of  extra  heavy  design  they  are  par- 
ticularly useful  in  securing  abdominal  hemostasis. 


Figure  943.    Kelly's  Compression  Forceps. 

Kelly's  Compression  Forceps,  as  they  appear  in  figure  943,  are  about  6 
inches  in  length  with  a  biting  or  compressing  surface  of  about  i  inch. 
The  jaws  are  slightly  curved  and  the  blades  so  adjusted  that  the  tips  grasp 
any  enclosed  tissues  before  contact  is  made  with  the  first  catch.  They  may 
be  used  not  only  for  clamping  a  small  artery  with  the  point  but  for  grasp- 
ing large  areas  of  tissue. 

Kocher's  Compression  Forceps,  represented  in  figure  944,  are  of  strong 
construction,  angular  bent  on  the  edge,  the  jaws  having  an  angle  of  about 
120°.  The  inner  faces  of  the  jaws  are  covered  with  fine  longitudinal 
grooves  that  extend  throughout  their  entire  length.  As  the  instrument  is 
supplied  with  several  catches,  any  desired  degree  of  pressure  may  be 
secured.  Its  usual  length  is  about  7  inches. 


VOLSELLUM    FORCEPS. 


423 


Figure  944.    Kocher's  Compression  Forceps. 

Volsellum  Forceps. 

Volsellum  forceps  are  provided  with  two  or  more  hook-like  teeth  so 
shaped  that  when  the  instrument  is  closed  the  prongs  will  become  embedded 
in  any  grasped  tissues.  They  differ  from  tenaculum  forceps  in  that  the 
latter  are  constructed  with  only  one  hook  upon  each  blade,  and  from  tissue 
forceps  in  being  provided  with  long  slender  hooks  somewhat  widely  sepa- 
rated, instead  of  teeth  that  closely  interlock. 

They  are  employed  in  surgery  for  holding  or  retracting  tumors,  organs 


Figure  945.    French  Pattern  Volsellum  Forceps. 


or  other  parts,  and  for  this  purpose  are  usually  constructed  with  handles 
provided  with  catches.  Other  patterns  will  be  found  described  under  the 
headings  of  Gynecological  and  Oral  Surgery. 

The  French  Pattern  Volsellum  Forceps  are  more  commonly  employed 
than  those  of  any  other  design.  The  locks  are  supplied  with  several  catches 
that  the  forceps  may  be  used  in  grasping  tissues  of  different  thicknesses, 
while  the  blades  are  slightly  curved,  permitting  the  handle  of  the  instru- 
ment to  rest  at  one  side  of  the  field  of  vision.  They  are  well  drawn  in 
figure  945,  and  may  be  procured  6,  8  or  10  inches  in  length,  with  or  without 
catches. 

Dressing  Forceps. 

Long  dressing  forceps  are  useful  for  grasping  folds  of  tissues,  holding 
small  organs  or  other  substances,  for  placing  or  removing  sutures  or 


Figure  946.    Laparotomy  Dressing  Forceps. 


ligatures,  for  packing  and  removing  gauze  from  cavities,  etc.  They  may 
be  of  the  ordinary  spring  forceps  type,  figure  608,  or  of  the  scissors  handle 
pattern  as  shown  in  figure  946, 


424 


LAPAROTOMY. 


Laparotomy  Dressing  Forceps  are  slender  instruments  of  the  scissors 
handle  pattern  and  provided  with  short  serrated  jaws  adapted  to  grasping- 
dressings  and  similar  substances  as  required  in  operations.  Usually  they 
are  about  8  inches  in  length.  They  are  delineated  in  figure  946. 

Long  Tissue  Forceps. 

Tissue  forceps  for  intra-peritoneal  plastic  use  do  not  differ  from  those 
described  by  figures  604  and  605,  except  in  length,  the  former  being  from 
7  to  8  inches  long. 


Figure  948.      Long  Curved  Tissue  Forceps. 

Tissue  Forceps  of  extra  length  for  abdominal  operations  may  be  procured 
with  3,  5,  7,  or  more  teeth,  and  either  straight  or  curved.  They  are  well 
traced  in  figures  947  and  948. 


'  Figure  949.    Kelly's  Tissue  Forceps. 

Kelly's  Tissue  Forceps,  as  defined  in  figure  949,  are  in  spring  handle  form 
with  broad  blades  and  slender  tips  terminating  in  delicate  mouse- teeth,  the 
latter  projecting  outward  at  an  angle  of  about  40°.  These  teeth  are  three 
in  number  and  mesh  closely  together.  The  regular  pattern  is  6^  inches 
in  length. 

Tenacula. 

Tenacula  for  abdominal  use  differ  from  those  described  on  page  278  in 
being  longer  in  handle  and  shank  and  smaller  in  the  hook-shaped  points. 
They  are  employed  for  grasping  and  holding  tissues  that  require  denuding 
or  excision,  lifting  up  vessels  that  require  ligation,  tucking  in  between 
sutures  any  pouting  edges  of  approximated  wound  margins,  and  exposing 
parts  jpr  better  examination.  The  heavier  patterns,  particularly  those 
shown  on  page  452,  also  serve  as  blunt  hooks  and  counter-pressure  instru- 

f  irn^.,. . 

Figure  950.    Sims'  Tenaculum. 

ments,  thus  avoiding  a  multiplicity  of  instruments.  Double  tenacula 
or  tenaculum  forceps  are  described  on  page  ooo.  As  they  are  frequently 
employed  in  pairs,  each  operating  set  should  contain  at  least  two.  Addi- 
tional patterns  will  be  described  in  the  section  on  gynecological  exami- 
nations. 

Sims'  Tenaculum,  as  shown  in  figure  950,  has  a  slender  shank,  with  the  tip 
bent  at  a  right  angle  and  with  the  point  bent  backward  at  an  angle  of  45°.  It 
is  a  useful  pattern  for  separating  and  holding  tissues  for  excision  when  large 


1NTRA-ABUOMINAL    NEEDLES. 


425 


areas  require  denudation.  On  account  of  its  short  hook,  tissues  may  quickly 
be  engaged  and  released.  This  pattern,  as  well  as  that  of  Dudley,  clearly 
delineated  by  figure  1019,  is  well  adapted  for  closely  adjusting  the  pouting 
edges  of  sutured  wounds. 


Figure  951.    Emmet's  Tenaculum. 


Emmet's  Tenaculum  consists  of  a  slender  shank  terminating  in  a 
slender  tip  bent  at  a  right  angle.  This  pattern  is  particularly  useful  in 
intra-abdominal  operations.  The  point  is  long  enough  to  secure  a  firm 
hold  and  fine  enough  for  delicate  dissections.  It  is  well  shown  in 
figure  951. 


Figure  952.     Kelly's  Shepherd's  Crook  Tenaculum. 

Kelly's  Shepherd's  Crook  Tenaculum,  while  particularly  designed  for  use 
in  the  operation  for  relaxation  of  the  vaginal  outlet,  will  be  found  useful  in 
many  other  cases  of  plastic  surgery.  Like  a  tenaculum  forceps  with  catch 
handle,  when  once  tissues  are  engaged,  this  instrument  may  be  repeatedly 
dropped  without  disengagement  of  attached  parts.  Its  form  is  plainly  set 
forth  by  figure  952. 

Intra- Abdominal  Needles. 

Needles  for  use  within  the  abdominal  cavity  in  cases  where  the  oper- 
ating space  is  narrow,  should  be  short,  and  in  most  cases  curved.  As 
tissues  of  a  friable  nature  frequently  require  uniting,  wire  needles  without 
cutting  edges  are  preferred  by  many  operators. 

Emmet's  Round  Needles,  as  shown  in  figure  953,  are  made  from  round 
wire,  without  edges  and  with  slender  conical  points.  They  may  be 
obtained  straight,  half  or  full  curved,  and  in  lengths  varying  from  ^  to  i  y2 
inches.  ' 

French  Fistula  Needles,  sometimes  called  "mouth  needles,"  as  exhibited 
in  figure  954,  have  straight  oval  shanks,  the  long  diameter  of  which  is 


Figure  953.    Emmet's  Round  Needles. 


Figure  954.    French  Fistula  Needles. 


vertical  or  in  a  plane  with  the  curve  of  the  needle.  The  body  of  the  needle 
is  flattened  laterally  and  curved  on  the  flat.  The  actual  sizes  are  shown  in 
the  illustration. 

Kelly's  Needles,  as  traced  full  size  in  figure  955,  have  straight  shanks  and 
curved  bodies  and  points,  the  straight  portion  extending  a  short  distance 
below  the  eye,  that  it  may  furnish  a  good  surf  ace  for  the  grasp  of  a  needle 


426 


LAPAROTOMY. 


holder.  The  eyes  are  relatively  large,  while  the  cutting  surface  is  no  wider 
than  the  body  of  the  needle.  The  curve  of  the  point  follows  the  long 
curve  of  the  body. 


Figure  955.    Kelly's  Gynecological  Needles. 


Figure  956.    Plain  Fistula  Needles. 


Plain  Fistula  Needles,  as  illustrated  in  figure  956,  differ  from  ordinary 
surgical  needles  only  in  that  they  are  full  curved  and  present  a  longer 
arc  of  a  circle.  They  are  made  in  three  sizes,  as  shown  in  the  illustration. 

Abdominal  Section  Needles. 

These  vary  in  design  from  plain,  straight  darning  needles  to  the  closing- 
eye  pattern  of  Reverdin.  Needles  of  the  shapes  ordinarily  employed  in 
general  surgery,  will  be  found  described  on  pages  332  to  334. 

Thomas'  Abdominal  Needle  is  a  straight,  sharp-pointed  instrument  of  the 
darning-needle  type,  as  set  forth  by  figure  957.  They  are  usually  about 


Figure  957.    Thomas'  Abdominal  Needle. 

2^/2,  inches  in  length  and  are  constructed  with  large  eyes,  thus  admitting  the 
use  of  heavy  sutures. 

Keith's  Abdominal  Needle  is  a  round,  slender,  highly-tempered  shaft, 
terminating  in  a  long   triangular  point.     The  usual  length  is  about 


Figure  958.    Keith's  Abdominal  Needle. 


inches.     Owing  to  their  peculiar  shape,  they  penetrate  dense  tissues  with- 
out the  exercise  of  much  force.     They  are  depicted  by  figure  958. 

Reverdin's  Closing-Eye  Needles  are  of  two  patterns,  straight  and  curved, 
as  displayed  by  figures  959  and  960.  Various  changes  in  lengths  and  curves 
have  been  suggested  by  different  operators,  the  illustrations  showing  the 


Figure  959.    Reverdin's  Straight  Needle  with  Closing  Eye. 

more  common  forms.  They  consist  of  a  slender  shaft,  the  distal  end  of 
which  is  provided  with  an  eye  that  may  be  opened  or  closed  at  the  will  of 
the  operator.  This  may  be  accomplished  by  means  of  a  sliding  bar  or  stylet, 
the  point  of  which,  when  pushed  forward,  forms  one  side  of  the  eye.  This 
enables  the  operator  to  easily  thread  the  needle  by  drawing  the  suture  into 
the  eye,  after  which  the  latter  may  be  closed  by  pushing  forward  the  thumb- 
piece  exhibited  in  the  illustration.  Thus  threaded,  it  may  be  introduced. 


ABDOMINAL    DRAINAGE    TUBES. 


427 


and,  after  being  passed  through  the  tissues  to  be  included,  the  eye  may  be 
opened,  the  suture  released  and  the  needle  withdrawn,  leaving  the  suture 
in  situ.  A  plan  more  commonly  employed  is  to  pass  the  needle  with- 
out thread,  introducing  the  latter  into  the  eye  after  the  point  protrudes  from 


Figure  960.     Reverdin's  Curved  Needle  with  Closing  Eye. 


the  needle  opening.  The  needle  on  withdrawal  carries  the  ligature  with 
it,  thus  securing  easy  introduction  of  the  latter.  As  this  needle  has  a 
fixed  handle,  it  can  be  directed  with  great  precision  and  accuracy. 

Abdominal  Drainage  Tubes. 

Drainage  tubes  of  sufficient  length  to  penetrate  to  the  floor  of  the 
wound  cavity  are  frequently  necessary.  To  meet  all  requirements,  an 
assortment  of  sizes  and  lengths  should  be  provided.  They  are  best  con- 
structed from  unyielding  material,  as  soft  rubber  or  similar  substance  is 
liable  to  collapse  by  pressure  of  surrounding  parts.  Glass,  aluminum  and 
silver  are  the  materials  usually  employed  in  their  manufacture.  Generally 
they  are  constructed  with  a  small  flange  at  the  proximal  end.  This  serves 
to  furnish  a  good  grip  for  withdrawal  of  the  tube,  and  it  also  prevents  a 
short  tube  from  slipping  wholly  within  the  cavity. 

They  may  be  procured  either  straight,  curved  or  bent  at  any  desired 


Figure  961.    Thomas'  Glass  Drainage  Tube. 


angle.  Some  patterns  are  constructed  with  straight,  plain  walls,  others  with 
bulb  tips,  and  many  with  the  distal  end  closed  in  the  form  of  an  ordinary 
test  tube.,  but  with  perforated  walls.  Ordinary  designs  are  open  at  the  distal 
end,  presenting  a  straight  lumen  from  end  to  end.  Others  are  closed  with 
the  exception  of  two  or  more  eyes  like  a  catheter,  and  again  patterns  have 
been  designed  with  only  small  side  openings  or  perforations. 

Thomas'  Glass  Drainage  Tube  is  slightly   curved  at  its  distal  third,   as 
shown  by  figure  961.     Usually  they  may  be  procured  in  external  diameters 


Figure  962.      Keith's  Plain  Drainage  Tube. 


varying  from  %  to  s/8  of  an  inch  and  from  2^4  to  8  inches  in  length,  and 
either  with  or  without  side  perforations. 

Keith's  Plain  Drainage  Tube  consists  of  a  glass  tube  T\  of  an  inch  in 
external  diameter  and  varying  from  4  to  6  inches  in  length.  The  distal 
end  is  closed  like  a  test  tube,  openings  being  provided  by  small  perfora- 
tions in  the  side.  The  tube  should  present  a  smooth  surface  similar  to 
that  shown  in  figure  962,  the  openings  being  so  constructed  as  not  to  tear 
the  wall  tissues  when  it  is  withdrawn. 

Keith's  Curved  Drainage  Tube,  as  defined  by  figure  963,  is  constructed 
with  a  bulbous  tip,  provided  with  large  lateral  openings.  A  flange  prevents 


428 


LAPAROTOMY. 


the   introduction  of  the  tube  beyond  a  desirable  depth,  while  the  enlarge- 
ment at  the  proximal  end  facilitates  the    introduction    of  gauze,   syringe 

T1O7716      GtC 

Tai't's  Drainage  Tube,  as  exhibited  by  figure  964,  has  a  bulbous  tip  perfor- 
ated with  numerous  small  openings.  It  is  also  provided  with  a  flange,  but 
differs  from  the  pattern  of  Keith  in  that  the  proximal  end  is  constructed 
for  the  attachment  of  a  rubber  hose  that  serves  to  facilitate  the  escape  of 
contained  fluids. 

Murphy's  Drainage  Tubes,  as  accurately  sketched  in  figure  965,  are  con- 
structed from  a  seamless  tube  of  metal,  usually  aluminum.  The  proximal 


Figure  963.    Keith's  Curved  Drainage  Tube 


Figure  964.    Tait's  Drainage  Tube. 


end  is  provided  with  a  flange^  while  the  distal  end  is  well  rounded,  and 
partially  closed  by  turning  in  the  outer  margin  The  distal  half  of  each 
of  these  tubes  is  provided  with  large  oval  openings  as  close  together  as 
possible.  The  lower  half  of  the  tube  thus  presents  the  appearance  of  a 
sieve  with  a  large  mesbu  This  construction  affords  a  ready  entrance  to 
abdominal  fluids,  and  its  inventor  claims  some  advantages  for  the  pattern 
in  this  respect. 

The  straight  pattern  may  be  obtained  in  four  sizes;  6  inches  in  length 


Figure  965.    Murphy's  Drainage  Tubes. 

by  24  mcri  in  diameter ;  5  inches  in  length  by  5/s  inch  in  diameter ;  6  inches 
in  length  by  ^  inch  in  diameter,  and  4  inches  in  length  by  ^  inch  in  diam- 
eter. The  curved  variety  is  obtainable  in  two  lengths,  6  inches  in  length 
by  5/8  inch  in  diameter,  and  6  inches  in  length  by  y2  inch  in  diameter. 

Additional  patterns  of  drainage  tubes  will  be  described  under  the  heading 
of  gynecological  surgery. 

Drainage  Tube  Syringe. 


Figure  966.      Syringe  for  Cleansing  Drainage  Tube. 


A  Syringe  for  Cleansing  Drainage  Tubes  is  frequently  necessary.  They 
may  be  made  of  metal  or  hard  rubber.  The  essential  feature  is  a  pipe  of 
sufficient  length  to  reach  to  the  bottom  of  the  tube.  Generally  they  are 
from  one  to  two  ounce  capacity  and  of  the  form  pictured  by  figure  966. 


ENTERORRHAPHY. 


429 


Abdominal  Supporters. 

The  Abdominal  Binder,  illustrated  by  figure  967,  consists  of  a  broad 
band  of  heavy  cotton  material  from  10  to  15  inches  in  width,  according  to 
the  size  of  the  patient,  and  of  a  length  equal  to  about  i%  times  the  cir- 
cumference of  the  patient  at  the  place  of  application.  Two  perineal  bands 
are  attached  to  the  lower  margin  of  the  bandage,  by  which  it  may  be  firmly 
held  in  place. 

Frank's  Appendicitis  Truss,  as  shown  in  figure  968,  consists  of  an  ovoid 
pad  of  large  size  and  firm  material,  held  in  place  by  a  body  strap  similar  to 
that  of  an  ordinary  truss.  The  pad  is  a  firm  plate,  usually  of  metal,  with 
a  soft,  elastic  padding.  The  lower  half  of  the  pad  is  supplied  with  a  cover 


Figure  907.     Abdominal  Binder. 


Figure  968.     Frank's  Appendicitis  Truss. 


that  it  may  serve  the  purpose  of  a  support  and  conform  to  the  shape  of  the 
abdomen  when  the  patient  is  in  an  erect  position.  The  body  straps  should 
be  so  placed  that  the  long  diameter  of  the  pad  may  be  directly  over  and  in 
a  line  with  the  incision.  It  is  supplied  with  a  perineal  band  by  which  it 
may  be  retained  in  any  desired  position. 

Enterorrhaphy. 

Under  this  heading  will  be  included  such  mechanical  appliances  as  are 
utilized  in  operations  in  the  continuity  of  the  intestinal  tract,  or  the  union 
of  any  of  the  hollow  viscera,  one  with  the  other,  or  with  an  intestine. 

In  addition  to  the  list  of  instruments  described  on  pages  270  and  414,  at 
least  a  portion  of  the  following  should  be  provided :  Anastomosis  buttons 
or  couplers;  forceps  for  introducing  same;  anastomosis  plates;  intestinal 
calibrator;  anastomosis  forceps;  intestinal  clamps,  and  intestinal  needles. 

Anastomosis  Buttons  or  Couplers. 

Anastomosis  buttons  or  couplers  are  mechanical  devices  by  which  sev- 
ered portions  of  the  hollow  viscera  may  be  united  usually  without  the  use 
of  sutures.  Generally  speaking,  they  consist  of  circular  collars,  provided 
with  some  form  of  a  locking  or  compressing  device,  so  adjusted  that  after 
each  is  secured  within  the  parts  to  be  joined,  the  whole  will  be  clasped  to- 
gether. When  in  situ  they  are  contained  wholly  within  the  canal,  held  in 
place  by  the  inverted  wound  margins  to  which  they  are  attached  by  pressure. 
Under  "pressure  atrophy"  these  margins  slough  off,  thus  freeing  the  appli- 
ance and  permitting  its  expulsion  per  rectum  by  peristaltic  action.  Union 
is  formed  at  the  margin  of  the  collars  by  contact  of  the  serous  surfaces. 
They  are  employed  in  intestinal  resections  and  anastomosis  operations. 


430 


LAPAROTOMV. 


The  advantages  claimed  for  them  by  Murphy,  who  devised  and  first  success* 
fully  employed  them,  are  union  usually  without  sutures,  a  great  saving  of 
time  in  application,  a  large  percentage  of  favorable  results,  and  simplicity 
in  technique. 

Murphy's  Anastomosis  Buttons,  as  detailed  in  figure  969,  consist  of  two 
bowl-shaped  hemispheres,  each  constructed  with  a  central  tube,  one  of 
\vhich  telescopes  within  the  other.  The  inner  surface  of  the  external  tube 
is  threaded,  while  the  outer  surface  of  the  female  tube  is  provided  with  two 
spring  catches  that  form  a  ratchet  connection  with  the  threaded  portion  of  the 


Figure  969.     Murphy's  Anastomosis  Buttons. 

external  tube.  The  face  of  one  of  the  hemispheres  is  movable,  resting  on  a 
spiral  spring,  just  strong  enough  to  hold  the  two  margins  in  close  contact,  and 
so  arranged  as  to  accommodate  intervening  tissues  thicker  on  one  side  than 
on  the  other.  When  in  situ  the  central  tube  is  parallel  with  the  intestinal 
tract,  and  through  it  semi-fluid  matter  may  readily  pass.  The  two  halves 
may  be  separated  by  unscrewing  the  threaded  tube.  Great  care  should  be 
exercised  in  the  construction  of  these  instruments,  as  slight  deviations  from 
the  correct  model  may  cause  operative  failure,  and  consequent  negative 
results.  The  exact  strength  of  the  spiral  spring  is  of  great  importance, 
but  not  more  so  than  the  shape  of  the  opposing  faces  of  the  hemispheres. 
These  should  present  circular,  or  well-rounded  surfaces,  that  the  inter- 
clasped  tissues  may  not  be  severed  by  pressure  from  too  sharp  an  edge.  The 
spring  should  be  just  strong  enough  to  hold  the  inverted  parts  in  place,  for 


u  b    u  b 


Longitudinal  Section.    '        Correct  Approximating  Faces.        Incorrect  Approximating  Faces. 
Figure  970.     Showing  Cross  Sections  of  a  Coi  rect  and  Incorrect  Model  of  Murphy's  Button. 

if  too  weak,  the  wound  margins  will  slip  out  from  between  the  faces,  while 
if  the  spring  be  too  strong,  the  intervening  parts  may  be  cut  away  by 
pressure  before  union  of  the  external  serous  margins  has  taken  place. 

These  sections  are  exhibited  to  enable  the  surgeon  to  determine  whether 
or  not  the  buttons  supplied  him  are  of  the  correct  model.  "A"  shows  the 
opposing  faces,  both  well  rounded  and  of  the  correct  pattern.  "B"  shows 
the  face  of  an  imperfect  model,  many  of  which  have  been  manufactured 
and  sold  by  dealers  who  doubtless  little  knew  the  dangers  that  would  beset 
the  surgeon  who  innocently  used  them. 

Murphy's  anastomosis  buttons,  as  shown  above,  are  manufactured  in 
four  sizes,  the  three  larger  of  which  are  employed  in  operations  on  adults 
and  children,  while  the  smallest  is  used  only  for  experimental  work  on  dogs 
and  other  small  animals.  The  outside  diameters  are  as  follows:  No.  o  (for 


ENTERORRHAPHY. 


431 


experimental  work),  ^  of   an  inch;  No.  i,  }jf  inch;  No.  2,  ||  inch;  No.  3, 
i  inch. 

Frank's  Anastomosis  Coupler  consists  of  two  decalcified  bone  collars 
that  in  external  appearance  do  not  differ  materially  from  the  Murphy  button. 
Instead  of  the  metallic  tube,  with  threads  and  spring  mechanism  for  hold- 
ing the  tissues  in  close  approximation,  a  piece  of  soft,  pure  gum  rubber 
hose  is  employed  in  such  a  manner  that  when  the  collars  are  in  contact  and 
the  ends  of  the  intestine  engaged,  a  slight  stretching  or  longitudinal  tension 
will  be  enforced  on  the  rubber  hose,  and  any  intervening  tissue  not  only 
firmly  held  but  eventually  severed  by  pressure  necrosis.  The  collars  are 


Figure  971.    Showing  Sections  of  Frank's  Anastomosis  Coupler  (Button). 

turned  from  sound,  compact  material,  such  as  may  be  obtained  from  the 
long  bones  of  young  oxen.  They  are  decalcified  in  a  ten  percent,  solution 
of  chemically  pure  hydrochloric  acid,  after  which  they  are  further  purified 
by  treatment  in  cologne  spirits,  alcohol,  etc.  In  their  manufacture,  thin, 
projecting  lateral  rims  are  provided  by  which  the  collars  are  attached  to  the 
ends  of  the  rubber  hose  by  thread  stitches.  The  two  collars  are  shown  in 
figure  971  before  attachment  to  the  hose,  while  the  same  figure  shows  the 
coupler  with  hose  attached. 

Figure  972  illustrates  the  coupler  completed,  while  the  same  figure  shows 
a  cross  section  of  the  button  when  in  service.  It  is  evident  that  the  natural 
processes  of  digestion  and  absorption  will,  in  a  short  time,  disintegrate  a 
coupler  of  this  character,  and  that  if  not  entirely  absorbed  the  decalcified 


Figure  972.     Showing  Frank's  Coupler  Complete  and  in  Longitudinal  Section  When  in  Use. 

bony  portion  will  at  least  become  separated  from  the  soft  rubber.  The 
intestinal  ends  to  be  anastomosed  are  turned  over  each  collar  and  crowded 
between  the  faces  of  the  two  hemispheres,  the  same  as  when  using  the 
Murphy  button.  This  procedure  necessarily  forces  the  two  hemispheres 
apart  and  stretches  the  rubber  hose,  causing  the  latter  to  exert  a  sufficient 
amount  of  pressure  upon  the  interposed  intestine  ends  to  cause  necrosis  of 
the  enclosed  parts.  Its  inventor  claims  that  the  operation  is  simplified  and 
time  saving,  that  the  foreign  substance  is  of  light  weight,  that  the  remaining 
soft  rubber  hose  can  be  safely  left  within  the  intestinal  canal,  and  that 
pathological  stenosis  of  the  lumen  does  not  follow.  As  usually  furnished 
by  instrument  makers  they  are  of  the  following  sizes: 


•132  LAPAROTOMY. 

if  inch  diameter,  for   cholecystenterostomy,  or  experimental  purposes. 

t  t  t  t  t  t  t  t  I  «  It  tt  t  t 

||    "  "  "     small  intestines. 

If    "  "  "         " 

large  or  small  intestines. 

"     "       "  "or  gastroenterostomy. 

"     large  intestine,  or   gastroenterostomy. 
.,.,',.  tt  tt         tt  it         tt      tt  tt 

ft 

Anastomosis  Button  Forceps. 

Anastomosis  button  forceps  are  employed  for  grasping  and  holding  the 
two  halves  of  a  button  while  the  latter  is  being  introduced  and  the  purse- 
string  suture  adjusted. 


Figure  973.      Murphy's  Button  Forceps. 

Murphy's  Button  Forceps,  well  traced  by  figure  973,  are  of  medium 
weight,  from  7  to  8  inches  in  length,  constructed  with  special  jaws,  the 
inner  surface  of  one  blade  being  concave,  and  of  the  opposing  one  convex, 
both  having  such  curves  as  will  securely  grasp  the  central  tubular  portion 
of  each  section  of  a  button. 

Bone  Plates. 

Bone  plates  consist  of  flat,  round  or  oval  discs,  employed  in  pairs,  each 
provided  with  a  central  opening  and  supplied  with  means  for  clasping  and 
securing  between  them  the  margins  to  be  united.  They  may  be  constructed 
of  metal,  hard  rubber,  decalcified  bone,  or  other  suitable  material.  By 
many  operators  they  are  considered  safer  than  buttons,  but  a  longer  time  is 
ordinarily  required  for  their  insertion 


l\ 


Figure  974.    Senn's  Decalcified  Bone  Plates,  for 
Anastomosis  and  Intestinal  Operations. 

Senn's  Bone  Plates,  as  represented  by  figure  974,  are  oval,  about  %  of  an 
inch  in  thickness,  made  from  the  compact  layer  of  an  ox  femur  or  tibia, 
and  decalcified.  Each  is  provided  with  a  central  opening,  as  shown  in  the 
illustration.  Previous  to  an  operation  each  is  supplied  with  four  sets  of 
double-threaded  sutures,  each  provided  with  a  needle.  The  procedure  con- 
sists in  cutting  a  slit  through  the  wall  of  each  of  the  parts  to  be  united, 


ENTERORRHAPHV. 


433 


passing-  one  plate  through  each  opening,  turning  them  with  the  face  out- 
ward, transfixing  each  wall  with  the  needles  and  sutures  above  referred  to, 
and  tying  the  various  sets  of  sutures  together,  thus  clasping  the  transfixed 
surfaces  between  the  plates  until  union  takes  place.  Their  great  advantage 
consists  in  the  security  of  the  parts  from  slipping  and  in  the  absorbable 
nature  of  the  foreign  substance. 

Anastomosis  Forceps. 

These  consist  of  forceps-like  clamps,  employed  to  hold  the  parts  to  be 
joined  while  the  sutures  are  being  inserted. 


Showing  One  Side  or  Half  of  Laplace's  Anastomosis  Forceps. 


Figure  975.     Laplace's  Anastomosis  Forceps. 

LaPlace's  Anastomosis  Instrument  really  consists  of  two  forceps,  each 
having  separable  blades,  one  resting  above  the  other,  close  contact  being 
secured  by  a  clamp.  When  thus  attached,  the  two  forceps  may  be  opened 
and  closed  as  a  single  instrument.  The  blades  comprise  two  rings,  one  of 
which  is  introduced  into  each  of  the  openings  to  be  anastomosed.  In  this 


Figure  976.      Showing  Full  Sizes  of  Blades  of  Laplace's  Anastomosis  Forceps. 

position  they  act  as  a  support  during  insertion  of  the  sutures.  The  latter 
may  be  of  any  desired  form,  and  may  extend  around  the  outer  surface  of 
the  forceps  blade,  and  the  parts  united  with  the  exception  of  the  limited 
space  occupied  by  the  shanks  of  the  instrument.  Upon  removing  the  clamp 

28 


434 


LAPAROTOMY. 


and  separating  the  blades,  the  latter,  owing  to  their  semi-circular  form,  may 
be  readily  withdrawn  from  the  tissues,  leaving  only  a  small  opening  that 
may  be  closed  with  one  or  two  additional  sutures,  thus  completing  the 
operation.  Their  inventor  claims  rapidity  and  accuracy  in  suturing  with- 
out leaving  a  foreign  substance  within  the  gut.  The)1-  are  manufactured  in 
five  sizes,  a  full  set  meeting  all  requirements,  varying  from  operations  on 
the  gall-bladder  to  those  involving  the  stomach  and  colon. 

Anastomosis  Calibrator. 

This  is  an  instrument  for  determining  the  exact  size  of  an  intestinal 
or  other  opening  to  be  united  by  anastomosis.  It  is  well  argued  that  in  select- 
ing an  anastomosis  button  or  coupler,  the  surgeon  should  first  ascertain 
the  caliber  of  the  smaller  opening  of  the  two  to  be  united.  It  is  evident 


Figure  977.    Frank's  Anastomosis  Calibrator. 

that  if  one  or  both  of  the  parts  be  placed  upon  an  unnatural  stretch,  it  may 
pass  over  the  collar  of  the  button  or  coupler,  and  that  partial  atrophy,  fol- 
lowed 'by  gangrene,  is  likely  to  result.  On  the  other  hand,  if  a  smaller  but- 
ton than  is  necessary  be  used,  cicatricial  contraction  is  likely  to  ensue. 

Frank's  Anastomosis  Calibrator,  as  depicted  in  figure  977,  consists  of  a 
truncated  cone,  the  external  surface  of  which  is  supplied  with  a  scale  by 
which  the  sizes  of  the  openings  to  be  anastomosed  may  be  accurately  deter- 
mined. By  means  of  a  handle  projecting  from  the  center  of  the  base  the 
instrument  may  be  manipulated. 

Intestinal  Clamps. 

Intestinal  clamps  consist  of  forceps  or  other  locking  devices,  constructed 
with  surfaces  adapted  to  exert  a  gentle  though  uniform  pressure,  holding 
an  intestine  or  similar  part  without  injury  to  its  tissues. 


Figure  978.     Murphy's  Intestinal  Clamp. 


Figure  979.    W athen's  Intestinal  Clamp  Forceps. 


Murphy's  Intestinal  Clamp  is,  as  delineated  in  figure  978,  a  self-acting 
spring  forceps,  the  blades  of  which  are  bent  at  a  right  angle  with  the 
handle.  The  spring  is  so  adjusted  that  it  will  exert  a  mild  pressure  and 
accommodate  tissues  that  may  be  thicker  on  one  side  than  the  other.  The 
blades  are  broad  and  covered  with  fine  transverse  serrations. 


ENTERORRHAPHY. 


435 


Wathen's  Intestinal  Clamp,  as  illustrated  in  figure  979,  consists  of  a  forceps 
of  the  scissors-handle  variety,  the  blades  of  which  resemble  two  long  and 
somewhat  slender  wire  loops.  When  in  use,  these  blades  should  each  be 
covered  with  pure  gum  tubing.  This  substance  furnishes  a  soft  yielding 
surface,  with  which  considerable  pressure  may  be  exerted  without  injury  to 
the  grasped  tissues.  The  length  of  the  fenestrated  portion  is  about 
2^  inches  by  y&  inch  in  outside  breadth,  while  the  total  length  of  the 
forceps  is  4^  inches. 

Knapp's  Intestinal  Clamp,  as  set  forth  in  figure  980,  differs  from  the 
one  last  described  chiefly  in  the  manner  in  which  pressure  is  applied.  The 


Figure  980.    Knapp's  Intestinal  Clamp. 

blades  are  of  the  same  construction,  excepting  that  the  fenestrated  portion 
is  about  3  inches  in  length  by  y2  inch  in  breadth.  When  in  use,  they  are 
covered  with  rubber  in  the  same  manner  as  in  Wathen's  clamp. 

Intestinal  Needles. 

Needles  for  suturing  the  abdominal  viscera  do  not  usually  have  cutting 
edges.  Many  operators  employ  a  plain  round  sewing  needle,  claiming  that 
sutures  thus  introduced  are  less  liable  to  tear  out,  and  that  they  inflict  less 
injury  to  the  involved  structures. 

Kelly's  Intestinal  Needles,  as  shown  full  size  in  figure  981,  are  con- 
structed with  the  patent  eye  shown  in  figure  749.  They  differ  from  the 


Figure  981.     Kelly's  Intestinal 
Needles. 


Figure  982.    Frank's  Intestinal 
Needles. 


Figure  983.    Mayo's  Intestinal 
Needles. 


regular  curved  pattern,  as  the  proximal  portion  of  the  shank  is  straight  and 
the  needle  curved. 

Frank's  Intestinal  Needles,  as  portrayed  full  size  in  figure  982,  are  deli- 
cate, half -curved  needles,  with  round  shanks  and  points  similar  to  ordinary 
sewing  needles.  They  differ  from  the  round  needle  of  Emmet  only  in  being 
more  slender  and  delicate.  They  are  constructed  with  eyes  of  good  size, 
that  they  may  be  easily  threaded.  The  lengths  are  usually  i  and  i^ 
inches. 

Mayo's  Intestinal  Needles  are  shaped  like  an  ordinary  cambric  needle 
with  a  straight  shank  and  full  curved  body,  the  latter  representing  a  half 
circle.  The  actual  sizes  are  shown  in  figure  983. 


CHAPTER  XXIII. 


GYNECOLOGICAL  SURGERY. 

The  instruments  employed  in  surgical  gynecology  may  be  divided  into 
those  for  vaginal  and  uterine  examinations,  urethral  and  bladder  examina- 
tions, ureteral  and  kidney  examinations,  curettage,  ovariotomy  by  abdomi- 
nal section,  treatment  of  uterine  fibroids,  perineorrhaphy,  trachelorrhaphy 
and  tracheoplasty,  closure  of  fistulas,  amputation  of  cervix  uteri,  hyster- 
orrhaphy,  Alexander's  operation,  uterine  applications,  uterine  displace- 
ments, general  electrical  treatment,  and  for  irrigation  and  support  of  the 
bladder.  Operations  that  do  not  require  special  instruments  are  omitted, 
because  it  is  intended  to  include  the  necessary  articles  in  some  one  of  the 
following  sections : 

VAGINAL  AND  UTERINE  EXAMINATIONS. 

For  these  the  following  instruments  are  usually  required : 

Table  or  chair. 

Vaginal  speculum,  for  exposing  parts  to  visual  examination. 

Depressor  for  retracting  the  soft  parts. 

Sounds  for  measuring  and  determining  condition  and  direction  of  uterine 
canal. 

Calibrator  for  measuring  vaginal  outlet. 

Probes  for  exploring  uterus,  etc. 

Tenacula  or  tenaculum  forceps  for  drawing  down  and  steadying  uterus. 

Volsellum  forceps  for  use  instead  of  heavy  tenacula. 

Dressing  forceps  for  holding  cotton,  gauze,  etc.,  for  swabbing  or  pack- 
ing purposes. 

Swabs  for  cleansing  or  wiping  away  discharges. 

Curette  or  syringe  for  removal  of  mucus. 

Sponge  holders. 

Dilator  for  enlarging  cervical  canal. 

Curette  for  removal  of  abnormal  growths. 

Aspirating  syringe  or  exploring  needle  for  determining  the  nature  of 
abscesses,  tumors,  etc. 

Rectal  speculum.     See  figures  2134  to  2147. 

Tables  and  Chairs  for  Examinations. 

The  proper  gynecological  examination  of  a  patient  requires  a  special 
piece  of  furniture,  either  a  table,  chair,  sofa  or  similar  article. 

The  essential  elements  of  construction  are  a  narrow  top,  either  horizon- 
tal or  one  that  can  be  rendered  so;  a  somewhat  firm  or  unyielding  mattress 
or  cover,  and  suitable  stirrups  for  holding  the  feet  of  the  patient.  Many 
gynecologists  insist  that  a  table  should  be  so  constructed  that  the  flat  hori- 
zontal top  may  be  changed  to  an  inclined  plane,  so  that  the  hips  and  lower 

436 


TABLES    AND    CHAIRS    FOR    EXAMINATIONS. 


437 


portion  of  the  body  may  be  elevated.  Others  prefer  to  make  use  of  Sims' 
position,  which  can  best  be  obtained  with  a  table  or  chair,  one  side  of  which 
(that  to  the  left  of  the  operator  when  facing  the  table  at  the  foot)  can  be 
raised  so  that  the  patient  rests  on  an  incline,  facing  downward,  half  turned 
on  the  abdomen.  When  the  latter  position -is  found  necessary  and  the  me- 
chanical adjustment  has  not  been  provided,  a  substitute  may  usually  be 
made  with  mattress,  blankets,  etc.  Some  operators  employ  a  table  or 
chair  that  permits  an  elevation  of  the  shoulders  and  head  with  a  view  of  flex- 


Figure  984.    Columbian  Operating  Table. 

ing  the  trunk  across  the  abdomen,  thus  forcing  the  viscera  downward  or 
nearer  to  the  vulva. 

The  Columbian  Operating  Table  consists  of  a  strong  frame,  manufac- 
tured from  either  walnut  or  oak,  and  so  adjusted  that  the  table  may  be  ar- 
ranged with  a  flat  top  of  sufficient  length  for  operating  purposes  or  shortened 
for  examinations.  By  a  specially  constructed  arrangement,  one  end  of  the 
top  may  be  raised  slightly  in  order  to  provide  for  an  elevation  of  the  hips 


Figure  985.     Allison's  Operating  Table. 


for  examinations,  or  it  may  be  elevated  sufficiently  to  secure  the  height 
necessary  for  the  Trendelenberg  position.  As  shown  by  figure  984,  the  table 
presents  a  neat  appearance  in  the  office,  and  if  covered  with  a  cloth  of  mate- 
rial that  can  be  washed  without  damage,  it  may  be  kept  in  a  cleanly  con- 
dition. The  height  of  the  table  is  32^,  width  24,  and  length  when  extended 
68  inches. 


438 


GYNECOLOGICAL    SURGERY. 


Allison's  Operating  Table  combines  many  of  the  desirable  features  of 
the  surgical  chair,  table  and  instrument  cabinet.  Although  occupying  no 
more  floor  space  than  an  operating  chair,  it  may  be  extended  into  a  table 
with  horizontal  top  74  inches  in  length.  Not  only  can  the  table  be  short- 
ened for  securing  the  dorsal  position  for  gynecological  examinations,  but  by 
a  special  lever  attachment  it  may  be  tilted  to  one  side  to  secure  Sims'  posi- 
tion. It  is  also  arranged  so  that  the  head  and  trunk  may  be  lowered  when 
required  during  anesthesia. 

The  lower  portion  of  the  table  is  furnished  with  a  revolving  instrument 
cabinet,  so  that  when  not  required  for  use,  the  instruments  resting  upon 


Figure  986.    Buchanan's  Folding  Operating  Table. 


open  shelves  may  be  secure  against  dust  and  light  contact.  Glass  trays  for 
solutions  also  form  a  portion  of  the  apparatus.  Crutches  are  provided  by 
means  of  which  any  desired  position  may  be  obtained.  Its  height  is  usually 
32  inches,  with  a  width  of  22  inches.  Its  general  outline  is  well  defined  in 
figure  985. 

Buchanan's  Folding  Operating  Table  is  constructed  wholly  of  iron,  and 
is  so  arranged  that  it  may  be  folded  in  a  compact  form.  For  this  reason  it 
is  particularly  applicable  for  examinations  and  operations  at  residences. 
The  table  top  is  in  three  pieces,  each  working  independent  of  the  other, 
and  so  adjusted  by  ratchet  bars  that  they  may  be  placed  in  any  desired 
position.  Either  the  head  or  foot  piece  may  be  raised  or  lowered  at  any 
angle,  while  one  end  of  the  center  may  be  elevated,  thus  securing  the 
Trendelenberg  position.  Stirrups  are  provided  by  means  of  which  the 
patient  may  be  placed  in  the  dorsal  position,  either  for  operations  or  exam- 
inations. As  ordinarily  manufactured,  and  outlined  by  figure  986,  it  is  20 
inches  in  width,  31  in  height,  and  when  extended  is  72  inches  in  length. 

The  Surgical  Chair,  shown  in  figure  987,  while  not  as  complicated  as  many 
that  are  in  the  market,  affords  all  the  advantages  necessary  for  ordinary 
examinations.  During  the  last  few  years  hospitals  have  increased  to  such 
an  extent  that  few  operations  are  now  performed  in  residences.  At  the 
residences  of  patients  an  ordinary  deal  or  a  special  folding  table  is  always 


VAGINAL    SPECULA.  439 

obtainable.  The  result  is  that  the  operating  chair  is  but  seldom  utilized 
for  major  operations,  and  that  complications  in  chair  construction  for  oper- 
ating purposes  are  no  longer  necessary.  The  chair  referred  to  may 
be  used  with  the  main  part  in  an  upright  position,  inclined  backward  at 
an  angle,  or  allowed  to  rest  on  a  level  with  the  seat.  The  lower  or  depend- 


Figure  987.    Surgical  Chair. 

ent  portion  of  the  chair  top  may  be  allowed  to  rest  as  traced  in  the  figure, 
or  raised  at  an  angle  until  it  is  horizontal  with  the  seat. 

A  great  number  of  operating  and  examination  chairs  are  now  on  the 
market,  many  of  which  are  of  great  merit  and  utility.  Among  these  the 
Harvard,  Yale,  Clark  and  Allison  are  the  best  known,  any  one  of 
which  will  be  found  generally  satisfactory. 

Vaginal  Specula. 

Specula  are  used  to  spread,  retract  or  dilate  the  vagina,  either  for 
purposes  of  examination  or  for  treatment.  They  ma)7  be  found  in  a  great 
variety  of  patterns,  all  of  which  may  be  classified  as:  Tubular,  uni-valve 
and  multi-valve. 

Tubular  Vaginal  Specula  embrace  all  of  the  cylindrical  patterns,  whether 
composed  of  glass,  porcelain,  metal,  rubber  or  other  material.  The  better 
designs  are  constructed  writh  a  flange  at  the  proximal  end  to  afford  a  shape 
easily  grasped  for  removal,  and  to  prevent  their  introduction  beyond  the 
depth  desired.  These  flanges  serve  to  prevent  the  soft  external  parts,  and 
such  coverings  as  are  used,  from  slipping  over  the  speculum  end  and  thus 
obstructing  the  field  of  vision.  The  distal  end  usually  terminates  in  a  face 
that  forms  an  oblique  angle  with  the  tube,  so  that  the  wall  of  one  side  is 
shorter  than  the  other.  As  the  short  side  of  the  speculum  forms  the  anterior 
wall,  when  introduced  to  the  proper  depth,  the  uterus  should  drop  into  the 
opening  thus  provided.  The  length  of  these  instruments  should  not  exceed 
^  to  5  inches,  and  in  external  diameter  they  vary  from  i  to  2  inches. 


440 


GYNECOLOGICAL    SURGERY. 


Ferguson's  Vaginal  Speculum,  as  illustrated  by  figure  988,  is  the  best 
known  of  this  class  of  instruments.  It  is  manufactured  of  glass,  the  outer 
wall  of  which  is  first  covered  with  a  layer  of  tin  foil,  over  which  a  coat  of 
black  varnish  is  smoothly  spread,  thus  furnishing  a  mirror  (speculum)  sur- 
face on  the  inner  portion  of  the  wall. 


Figure  988.    Ferguson's  Vaginal  Speculum. 

For  many  years  this  formed  the  standard  instrument  for  examinations 
and  treatment,  and  through  them  even  many  minor  operations  were  per- 
formed. While  valvular  specula  are  of  great  antiquity,  their  general  use  is 
of  only  recent  origin.  Tubular  specula  are  at  present  but  little  employed 
in  this  country,  because  not  only  is  the  field  of  vision  limited,  but  the  en- 


Figure  989.    Set  of  Four  Tubular  Specula. 

g-agement  of  the  cervix  in  the  proximal  end  is  sometimes  difficult,  and  their 
introduction  usually  more  painful.  They  are  easily  fractured,  and  unless 
great  care  is  taken  the  varnished  surface  soon  becomes  rough  and  abraded. 
A  Set  of  Four  Tubular  Specula,  as  shown  by  the  illustration  in  figure 
989,  exhibit  a  set  of  metal  or  hard  rubber  specula  of  the  Ferguson  pattern 


Figure  990.    Kelly's  Tubular  Speculum  for  Use  in  the  Virgin. 

''nested"  in  compact  form.  While  more  durable  and  not  as  likely  to  be- 
come roughened  by  use,  they  are  seldom  employed  by  American  physicians. 
In  many  foreign  countries,  however,  they  are  still  extensively  used.  The 
sizes  usually  vary  from  ^  to  i^  inches  in  diameter,  and  from  4^  to  6 
inches  in  length. 

Kelly's  Tubular  Specula,   delineated  by  figure  990,  include  numbers  1 2  to 
15  of  the  cystoscopic  set.     Owing  to  their  small  diameter  they  may  be  sue- 


VAGINAL    SPECULA. 


441 


cessfully  used  in  the  virgin  in  cases  where  the  larger  patterns  could  not  be 
introduced. 

Uni-Valve  Vaginal  Specula  are  especially  useful  because  they  occupy 
little  space  within  the  vagina,  because  they  can  be  used  as  specula  or 
retractors,  and  because,  in  certain  cases,  they  serve  to  shield  the  tissues 
from  instrumental  injury.  These  specula  are  all  modifications  of  the  pat- 
tern designed  by  the  late  Marion  Sims,  who,  by  the  invention  of  this  one 


Figure  991.    Sims'  Speculum. 


Figure  992.    Mund6's-Sims'  Speculum. 


instrument,  made  possible  much  of  the  great  advance  in  gynecology  dur- 
ing the  latter  half  of  the  ipth  century.  So  universal  is  their  use  that 
scarcely  a  major  gynecological  operation  is  now  attempted  without  em- 
ploying either  a  Sims  speculum  or  some  modification  of  it.  So  carefully 
were  his  plans  perfected  that  to-day,  with  designers  by  the  hundred,  who 
have  sought  to  produce  an  "Improved  Sims'  Speculum,"  not  a  single  one 


Figure  993.    Bozeman's-Simon's  Set  of  Sims' 
Specula. 


can  be  found  that  is  considered  the  equal  of  the  original,  or  that  has  com- 
manded a  sale  equal  to  one  per  cent,  of  the  pattern  as  first  given  to  the 
world  by  Sims. 

Many  modifications  of  the  Sims  speculum  have  been  named  by  their 
designers  "retractors. "  As  the  latter  are  specula,  according  to  the  generally 
accepted  meaning  of  the  word,  and  as  they  are  constructed  with  but  one 
blade,  they  will  be  included  under  this  heading. 


442 


GYNECOLOGICAL    SURGERY. 


Sims'  Speculum,  as  displayed  by  figure  991,  exhibits  a  double  Sims 
speculum  of  the  ordinary  type.  When  properly  manufactured  they  consist 
of  two  specula,  one  somewhat  smaller  than  the  other,  united  by  a  stiff 
handle  slightly  curved  downward  in  the  center.  The  blades  are  short,  quite 
concave,  and  each  bent  at  a  little  more  than  a  right  angle  with  the  handle. 
In  their  selection  the  operator  should  choose  those  with  thin  blades.  Many 
are  made  with  thick,  heavy  castings,  frequently  full  of  sand  holes  and  thus 
difficult  to  clean ,  while  others  are  flat,  badly-shaped  and  poorly-constructed 


Figure  994.    Martin's-Sims'  Speculum 


instruments  that  differ  materially  from  the  original  model.  They  may  be 
purchased  in  a  variety  of  sizes.  A  set  of  three,  however,  furnishing  blades 
^  to  i^  inches  in  width,  will  supply  the  operator  with  as  large  an  assort- 
ment as  will  be  found  necessary.  A  special  operating  speculum,  i^  inches 
in  width,  can  also  be  obtained. 

Munde's-Sims'  Speculum.  The  advantages  claimed  for  this  pattern 
consist  in  a  broadening  of  the  upper  border  of  the  blade  margin,  so  that 
with  a  patient  in  the  Sims  position,  it  serves  as  a  guard  or  shield  by  which 
the  nates  are  prevented  from  overlapping  the  edge  of  the  speculum  and 
obstructing  the  field  of  vision.  As  drawn  in  figure  992,  the  usual  blade 
widths  are  if£  inches  for  the  larger  and  i^  inches  for  the  smaller  end. 


Figure  995.    Simon's-Sims'  Speculum. 


Bozeman's-Simon's  Set  of  Sims'  Specula  comprise  two  handles,  to  either 
of  which  may  be  attached  any  one  of  the  eight  blades  forming  the  set 
detailed  by  figure  993.  Half  of  the  blades  are  of  a  concave  pattern  while 
the  balance  are  of  the  flat  or  so-called  retracting  type.  Taken  together 
the  entire  combination  forms  a  convenient  outfit  for  either  examination  or 
operation.  The  attachment  of  the  blade  to  the  handle  is  by  a  slip  joint 
readily  separated  and  easily  cleansed.  The  body  of  the  handle  is  deeply 
corrugated  and  terminates  in  a  curve,  the  whole  forming  a  grip  easily  main- 
tained for  a  considerable  period.  Patterns  of  this  or  a  similar  form  are 
largely  used  by  German  operators.  When  in  use,  the  patient  is  usually 
placed  in  the  dorsal  position. 


VAGINAL    SPECULA.  443 

Martin 's-Sims'  Speculum,  as  clearly  shown  by  figure  994,  has  an  exceed- 
ingly short,  somewhat  concave  blade  terminating  in  a  long  shank  and  a 
handle  of  the  pattern  last  described.  The  terminal  border  of  this  blade  is 
somewhat  concave,  as  are  also  the  lateral  margins.  The  external  portion  of 
the  speculum,  is  broadened  into  two  flanges,  that  serve  as  guards  to  pre- 
vent obstruction  of  the  field  of  vision  by  the  overlapping  of  the  external 
parts.  The  instrument  may  be  purchased  in  three  sizes,  the  widest  part  of 
the  blade  being  i^,  2  and  2^  inches,  respectively. 

Simon's-Sims'  (Retractor)  Speculum,  as  accurately  indicated  by  figure 
995,  is  so  far  removed  in  its  general  design  from  the  model  of  Sims  that  it 
might,  with  propriety,  be  termed  a  retractor,  the  name  given  to  it  by  its 
designer.  For  reasons  before  given,  however,  we  include  it  in  the  speculum 
class.  It  consists  of  a  flat,  straight  blade  i  inch  in  width  and  about  4 
inches  in  length,  terminating  in  a  straight  shank  and  with  the  handle  bent 
at  a  right  angle  with  the  blade.  It  is  frequently  used  in  connection  with  a 
speculum  of  the  Sims  model. 

EdebohPs-Sims'  Speculum,  as  illustrated  by  figure  996,  is  a  modification 
of  the  Sims  pattern  and  consists  of  an  arrangement  by  which  a  Sims  specu- 


Figure  996.    Edebohl's-Sims'  Speculum. 

lum  may  be  used  without  the  services  of  an  assistant.  It  is  a  short  Sims 
blade,  the  open  part  of  which  projects  externally  in  the  form  of  a 
trough,  the  latter  terminating  in  a  tube,  to  the  lower  end  of  which  a  weight 
may  be  attached.  The  speculum  devised  by  Edebohl  includes  as  a  part  of 
the  outfit  a  small  tin  pail  that  may  be  filled  with  water,  sand  or  other 
material  that  will  give  the  speculum  sufficient  weight  to  produce  the  neces- 
sary retraction.  The  speculum  is  compact,  presenting  a  flat  surface  about 
i^  inches  in  width  and  2^  inches  in  length,  while  the  entire  length  of  the 
instrument  does  not  exceed  4  inches. 

Auvard's  Speculum,  as  explained  by  figure  997,  differs  from  the  pattern 
last  described,  principally  in  the  handle,  which  is  longer  and  contains  a 
bulbous  enlargement  of  solid  metal,  the  weight  of  which,  added  to  that  of 
the  speculum,  constitutes  a  retraction  force  sufficient  for  operative  purposes. 
Broad  lateral  flanges  upon  either  side  prevent  the  soft  parts  from  project- 
ing into  and  obstructing  the  field  of  vision.  The  handle  is  constructed  with 
a  slot  extending  along  its  anterior  margin,  thus  permitting  of  the  ready 
cleansing  of  the  conducting  canal.  The  lower  end  of  the  handle  is  arranged 
for  attachment  to  a  rubber  hose.  The  blade  of  the  speculum  is  sharply 
curved  upon  the  handle,  thus  producing  retraction  of  the  vaginal  wall. 
The  weight  of  the  instrument  usually  varies  from  2  to  3^  pounds. 

Multi-Valve  Specula,  as  the  name  implies,  are  provided  with  two  or 
more  blades.  They  are  so  numerous  in  design  that  only  a  few  of  those 
deemed  best  adapted  for  general  use  will  be  included  in  this  chapter.  As 


444 


GYNECOLOGICAL    SURGERY. 


a  rule,  the  less  the  number  of  blades  in  a  speculum,  the  better  the  instru- 
ment. Would-be  inventors  of  this  class  of  appliances  are  advised  to  study 
simplicity  and  avoid  complicated  designs  and  multiple  parts.  Frequent 
efforts  have  been  directed  to  construct  specula  that  can  be  used  for  differ- 
ent purposes,  as,  for  instance,  a  bi-valve  that  may  be  converted  into  a  Sims. 
During  the  years  that  such  instruments  were  sold  at  prices  two  to  five  times 
those  that  arc  paid  to-day,  there  might  have  been  a  good  reason  for  such 
combinations,  but  now  that  these  instruments  can  be  purchased  for  a 
small  sum,  there  remains  no  excuse  for  a  combination  of  these  two  instru- 
ments, for  in  their  construction  the  essential  features  of  one  or  both  are 
often  deficient.  Vaginal  specula  with  more  than  three  blades  are  generally 


Figure  997.    Auvard's  Speculum. 

considered  useless,  and  as  they  are  practically  obsolete,  they  will  not  be  in 
eluded  in  this  work. 

Generally  speaking,  it  is  claimed  that  vaginal  specula  are  too  long. 
The  earlier  models  were  constructed  with  blades  that  could  be  introduced 
to  a  depth  of  from  4  to  5  inches.  A  gradual  decrease  in  the  length  of 
these  instruments  has  taken  place  until  at  this  writing  many  may  be 
obtained,  the  anterior  blade  of  which  does  not  exceed  2  inches,  and  the 
posterior  from  2  ^  to  3  inches  in  length. 

Miller's  Speculum,  as  shown  by  figure  998,  illustrates  one  of  the  simplest 
and  most  satisfactory  instruments  of  this  class.  It  consists  of  two  blades 


Figure  998.    Miller's  Speculum. 

of  the  "duck  bill"  pattern,  hinged  at  their  proximal  ends,  where  they 
curve  outward  in  the  form  of  a  flange.  When  slightly  opened,  the  blades 
bear  a  close  resemblance  to  the  original  Ferguson  speculum,  and  in  gen- 
eral contour  the  instrument  is  not  unlike  the  old  cylindrical  model  divided 
into  longitudinal  halves,  and  hinged  at  the  base  so  that  the  distal  ends  may 
be  spread  apart.  Upon  one  side  the  blades  are  each  extended  into  handle 
bars  that  pass  posterior  to  the  hinge,  by  means  of  which  expansion  is 
secured.  The  amount  of  dilatation  produced  and  maintained  is  regulated 
by  a  screw  device. 

As  is  usual  in  the  construction  of  instruments  of  this  class,  the  anterior 


VAGINAL    SPECULA. 


445 


blade  is  shorter  than  the  posterior,  thus  permitting  the  cervix  to  slip  by  or 
over  the  well-rounded  end  of  the  former,  appearing  in  view  above  the 
longer  and  cup-shaped  blade  of  the  latter.  A  slot  extending  forward  from 
the  base  of  the  anterior  blade,  usually  for  about  \y2  inches  in  length  and 
from  ^  to  y%  inch  in  breadth,  prevents  pressure  upon  the  meatus  urinarius 
externus. 

This  pattern  is  usually  manufactured  in  three  sizes,  the  dimensions  of 
the  posterior  blade  of  the  large  size  being  about  sH  inches  in  length  by 


Figure  999.     Higbee's  Speculum. 


Figure  1000.    Woman's  Hospital  Speculum. 


i  y%  inches  in  breadth ;  that  of  the  medium,  3  ^  inches  in  length  by  i  l/i  inches  in 
breadth ;  while  the  smaller  is  3  inches  in  length  by  about  ^  inch  in  breadth. 
The  Woman's  Hospital  Speculum,  sometimes  called  a  finger  speculum 
because  used  as  a  vaginal  dilator,  is  perhaps  one  of  the  smallest  of  this  class 
of  instruments.  The  blades  are  slender,  of  nearly  the  same  pattern  and  of 
equal  width  and  length,  so  that  when  they  rest  with  faces  together  the 
instrument  is  conical.  Their  length  is  about  3  inches  with  a  diameter 


Figure  1001.    Graves'  Speculum. 


Figure  1002.    Abbott's  Speculum. 


varying  from  ^  inch  at  the  base  to  about  ^  inch  near  the  extremity.  As 
portrayed  by  figure  1000,  the  blades  are  hinged  an tero- posteriorly  and  sup- 
plied with  a  cross-bar  and  set  screw,  by  means  of  which  any  desired 
amount  of  blade  expansion  may  be  secured. 

Higbee's  Speculum  differs  from  the  pattern  of  Miller  in  the  method 
employed  to  secure  dilatation,  in  the  manner  of  forming  the  external 
flange,  and  in  the  absence  of  a  slot  in  the  anterior  blade.  As  drawn  in 
figure  999,  the  valves  are  more  nearly  straight,  the  anterior  one  being 


446 


GYNECOLOGICAL    SURGERY. 


enlarged  at  its  proximal  end  into  a  circular  flange  that  forms  the  base  of 
the  instrument.  This  flange  is  considered  advantageous  for  keeping  the 
soft  parts  and  coverings  out  of  the  field  of  vision.  While  this  pattern 
occupies  as  much  vaginal  space  as  the  one  above  referred  to,  the  area  at 
the  vaginal  entrance  is  more  limited.  It  is  manufactured  in  three  sizes, 
the  length  of  the  posterior  blade  of  the  large  size  being  3^  inches  with  a 
breadth  of  i^  inches,  the  medium,  3^  inches  in  length  by  \%  inches 
in  breadth,  and  the  small  3^  inches  in  length  by  fa  inch  in  breadth. 

Graves'  Speculum,  as  shown  by  figure  1001,  was  designed  to  combine  a 
bi- valve  and  a  Sims  speculum  in  a  base-expanding  instrument.  Its  con- 
struction displays  considerable  ingenuity.  It  was  devised  at  a  time  when 
this  class  of  instruments  was  quite  expensive,  and  its  inventor,  no  doubt, 
sought  to  supply  an  apparatus  adapted  to  many  uses.  The  blades  in  shape 
are  not  unlike  those  of  the  Higbee  pattern,  previously  described.  The 
lower  or  posterior  is  elongated  at  its  proximal  ending  into  a  straight  handle 


Figure  1003.    Cavana's  Speculum. 


Figure  1004.    Cordier's  Speculum. 


bar  about  3  inches  in  length,  in  the  center  of  which  a  slot  is  provided. 
The  anterior  blade  is  lengthened  upon  one  side  into  a  depressing  bar  by 
means  of  which  the  tips  of  the  blades  may  be  spread.  The  amount  of  this 
expansion  is  regulated  and  maintained  by  a  screw  device.  This  blade  is 
hinged  upon  both  sides  with  a  forked  bar,  the  shaft  of  which  is  also  slotted 
and  provided  with  a  pin  and  stop-screw  that  acts  by  a  sliding  movement 
with  a  similar  slot  in  the  posterior  blade.  This  furnishes  the  adjusting 
mechanism  by  which  the  base  is  expanded.  By  means  of  the  screw  device 
referred  to,  the  blades  may  be  separated,  turned  in  opposite  directions  and 
again  secured,  when  a  fairly  good  Sims  speculum  results. 

Abbott's  Speculum  is  probably  constructed  with  shorter  blades  than 
any  other  pattern  on  the  market  at  this  writing.  It  consists  of  two  blades, 
one  fixed  upon  a  square  bar,  the  other  attached  to  a  slide  arranged  to  move 
backward  and  forward  along  this  bar.  The  upper  blade  is  ^f  of  an  inch 
in  breadth  and  about  2  inches  in  length,  the  lower  one  being  i^  inches  in 
breadth  and  about  2^  inches  in  length.  By  means  of  a  lever  and  thumb- 
screw the  lower  blade  may  be  depressed  and  any  desired  angle  secured. 
The  instrument  is  light,  compact,  and,  we  believe,  a  desirable  pattern. 
Its  essential  features  are  set  forth  in  figure  1002. 

Cavana's  Speculum,  as  portrayed  in  figure  1003,  practically  consists  of 


VAGINAL    SPECULA. 


447 


a  short  but  otherwise  enlarged  speculum  of  the  pattern  of  Hale  (once 
quite  popular),  the  controlling  mechanism  being  identical.  The  blades 
are  i^  inches  in  width  by  2  inches  in  length,  the  speculum  opening  being 
2^3  inches  in  breadth  and  capable  of  a  3-inch  vertical  extension.  The 
instrument  is  particularly  adapted  for  class  examinations  and  may,  in  some 
cases,  be  utilized  for  operative  purposes. 

Cordier's  Speculum  presents  a  new  feature  in  the  construction  of  bi-valve 
vaginal  specula,  as  indicated  by  figure  1004.  It  is  arranged  with  a  series 
of  slots,  by  means  of  which  any  desired  amount  of  expansion  at  the  base 


Figure  1005.     Rockeys  Speculum. 

may  be  secured  without  interfering  with  or  impairing  the  amount  of 
expansion  at  the  tips  of  the  instrument.  The  lower  or  fixed  blade  is  pro- 
vided upon  its  outer  margin  with  pins,  each  with  heads  of  the  French  lock 
pattern.  Three  slots  provided  in  the  lateral  extensions  of  the  upper  blade 
permit  the  setting  of  the  instrument  at  any  desired  width.  A  hinged 
lever  attached  to  this  blade,  and  caused  to  act  in  connection  with  a  ratchet 
bar  extending  perpendicularly  from  the  flat  surface  of  the  lower  blade, 
fixes  the  amount  of  dilatation  secured  at  the  tip.  It  will  thus  be  seen  that 


Figure  1006.    Nott's  Tri- Valve  Speculum. 

the  speculum  may  be  adjusted  to  various  cases.  The  objectionable  features, 
as  a  Sims  speculum,  are  its  complicated  parts,  the  whole  furnishing  a  Sims 
blade  considered  by  most  operators  as  both  too  long  and  too  flat. 

Rockey's  Speculum,  as.  outlined  in  figure  1005,  is  a  single-blade 
speculum  of  the  Martin  type,  to  which  an  anterior  blade  may  be  attached 
and  actuated  by  a  simple  device.  Its  relative  distance  above  the  posterior 
blade  may  be  regulated  by  a  ratchet  bar,  operated  by  thumb  and  finger 
movement.  The  posterior  blade,  is  2^  inches  in  length  and  i^  inches  in 
breadth,  while  the  anterior  is  but  2  inches  in  length  and  ij^  inches  in 


448 


GYNECOLOGICAL    SURGERY. 


breadth.  The  instrument  is  of  heavy  design,  that  it  may  furnish  by  its 
own  weight  a  certain  amount  of  traction  force.  It  is  particularly  adapted 
for  operations  and  for  use  as  a  Sims  speculum  where  the  services  of  an 
assistant  can  not  be  conveniently  secured. 

Nott's  Tri-Valve  Speculum  consists  of  a  fixed  posterior  blade  to  which  are 
hinged,  each  independent  of  the  other,  two  anterior  blades,  the  proximal 
ends  of  the  latter  expanding  into  arms  so  shaped  that  they  are  engaged  by 


Figure  1007.     Nelson's  Speculum. 


a  fly-nut  acting  upon  a  screw  rod  attached  to  the  lower  blade.  By  means 
of  this  nut  any  desired  amount  of  tip  expansion  may  be  secured.  The 
posterior  blade,  which  extends  about  ^  inch  beyond  the  anterior  blades,  is 
about  3  inches  in  length  by  i  inch  in  breadth.  Figure  1006  represents  the 
medium  size,  a  large  and  a  small  size  being  provided  for  special  cases. 

Nelson's  Speculum  differs  from  the  pattern  of  Nott  in  that  the  exten- 
sions of  the  anterior  blades  are  constructed  in  the  form  of  handles,  expan- 
sion being  secured  by  a  cross-bar  and  thumb  screw,  extending  from  one 


Figure  1008.    Lenneker's  Tri-Valve 
Speculum. 


handle  to  the  other.  The  instrument  is  longer  than  the  pattern  of  Nott, 
the  posterior  blade  being  4  or  more  inches  in  length  with  a  width  of  i^ 
inches.  It  is  well  shown  by  figure  1007. 

Lenneker's  Tri-Valve  Speculum,  as  exhibited  by  figure  1008,  is  also  a 
modification  of  the  pattern  of  Nott,  but  differs  in  the  method  of  securing 
expansion.  The  anterior  blades  in  this  speculum  extend  backward  about 
i  inch,  where  they  are  each  connected  with  a  jointed  arm  that  is  attached 
to  a  screw  rod  that  extends  posteriorly  through  a  slot  provided  in  an  exten- 
sion of  the  lower  blade.  A  fly-nut  upon  this  bar  secures  any  amount  of 
dilatation  required. 


VAGINAL    DEPRESSORS. 


Vaginal  Depressors. 


449 


These  instruments,  sometimes  called  retractors,  usually  consist  of  loop 
or  spatula- shaped  blades,  employed  in  connection  with  uni-valve  specula 
to  depress  or  force  back  the  anterior  vaginal  folds  in  cases  where  they 
obstruct  a  view  of  the  cervical  field. 


Figure  1009.    Showing  Sims'  Original  Depressor. 

Sims'  Original  Depressor  was  improvised  by  forming  a  loop  in   a  soft 
copper  sound,  as  illustrated  in  figure  1009. 

Sims'  Double-End  Depressor,  as  usually  manufactured,  consists  of  a  slen- 


Figure  1010.    Sims'  Double-End  Depressor. 

der  handle  with  a  slight  double  curve,  each  end  terminating  in  an  ovoid 
loop,  as  explained  by  figure  1010.  The  larger  loop  is  about  1^3  inches  in 
external  diameter,  while  the  smaller  has  a  diameter  of  ^  inch,  the 
extreme  length  of  the  instrument  being  from  8  to  9  inches. 


Figure  1011.    Bozeman's  Depressor. 

Bozeman's  Depressor  consists  ot  a  handle  and  shank  terminating  in  a 
spatula-shaped  blade.  It  is  double  curved  and  convex  upon  its  posterior 
or  contact  surface.  As  sketched  in  figure  ion,  it  resembles  in  shape  the 
posterior  blade  of  a  narrow  bi-valve  vaginal  speculum.  Its  length  is  about 
8  inches,  the  width  of  the  blades  being  from  to  i  inch. 


Figure  1012.    Hunter's  Depressor. 

Hunter's  Depressor  consists  of  two  flat,  spoon-shaped  blades  united  by 
a  firm  handle.  As  appears  in  figure  1012,  the  larger  blade  is  about  i  inch 
and  the  smaller  about  ^  inch  in  breadth,  with  a  total  length  of  8*4  inches. 
As  the  concave  surfaces  of  the  two  blades  face  in  opposite  directions,  the 
end  not  in  use  as  a  depressor  serves  as  a  convenient  handle. 

Uterine  Sounds. 

These  consist  of  slender,  rod-like  instruments  employed  to  measure  the 
depth  and  direction  of  the  uterine  cavity,  as  a  lever  to  correct  displace- 
ments, and  as  a  means  of  determining  the  presence  or  extent  of  uterine 
growths. 

They  are  usually  constructed  of  soft  copper,  rigid  brass  or  spiral 
elastic  steel,  somewhat  curved  at  the  distal  end  and  bulb-pointed,  the 

29 


450 


GYNECOLOGICAL    SURGERY, 


proximal  portion  of  the  shaft  terminating  in  a  flat  handle,  one  side  of  which 
is  corrugated.  As  this  is  usually  the  side  toward  which  the  instrument  is 
curved,  the  operator  may  know  the  course  of  the  canal  while  the  instru- 
ment is  in  situ.  They  may  be  obtained  either  p^ain  or  graduated  in  inches. 


Figure  1013.    Simpson's  Uterine  Sound. 

Simpson's  Uterine  Sound  is  a  somewhat  rigid  rod,  flexible  before  intro- 
duction, and  provided  with  a  corrugated  handle  as  above  described.  The 
instrument  is  usually  about  1 1  inches  in  length,  the  shaft  being  graduated 
in  inches  and  quarters.  As  shown  by  figure  1013,  a  slight  knob  formed  in 
the  shaft  of  the  instrument,  2^  inches  from  the  distal  end,  denotes  the 
average  normal  depth  of  the  uterine  pavity.  The  tip  of  the  instrument  is 
enlarged  into  a  rounded  bulb,  in  order  to  avoid  injury  to  the  fundus. 


Figure  1014.    Sims'  Uterine  Sound. 

Sims'  Uterine  Sound  differs  from  Simpson's  in  being  made  from  a  soft 
copper  rod,  that  it  may  be  curved  by  slight  pressure.  It  is  constructed 
without  the  measuring  knob  and  is  not  graduated.  It  is  portrayed  by 
figure  1014. 

Fitch's  Uterine  Sound  differs  from  the  patterns  previously  described  in 
the  method  employed  for  measuring  the  depth  of  the  uterine  cavity.  The 
instrument,  as  illustrated  by  figure  1015,  consists  of  a  Sims  sound  sur- 
rounded by  a  spiral  wire  sheath,  arranged  by  means  of  a  set  screw  so  that 
it  may  be  fixed  upon  the  shaft  in  any  desired  position.  The  proximal 


Figure  1015.    Fitch's  Uterine  Sound. 

half  of  the  shaft  is  slightly  flattened  upon  one  side,  that  it  may  serve  as  a 
face  for  graduation.  This  scale  serves  as  a  means  for  measuring  the  dis- 
tance between  the  distal  end  of  the  sheath  and  the  point  of  the  instrument. 
In  measuring  the  depth  of  the  uterus  with  a  plain  sound,  it  is  customary  to 
slip  the  finger  along  the  rod  until  the  tip  reaches  the  external  os,  the  point 


Figure  1016.    Jenks'  Uterine  Sound. 

of  contact  being  measured  by  the  nail  or  finger  tip  where  it  rests  against 
the  sound.  The  sheath  in  this  instrument  is  used  to  replace  the  finger, 
the  depth  of  the  uterus  being  marked  as  above  stated. 

Jenks'  Uterine  Sound,  as  displayed  by  figure  1016,  combines  the  meas- 
uring features  of  the  Fitch  sound  with  a  spiral  elastic  rod.     The  latter  is 


UTERINE    PROBES.  451 

sufficiently  flexible  to  readily  conform  to  the  shape  or  direction  of  the  uter- 
ine canal.  As  the  diameter  of  the  instrument  decreases  with  its  length,  it 
is  quite  elastic  near  the  tip,  which  is  of  bulbous  form.  The  spiral  sheath 
of  the  pattern  previously  described,  is  here  replaced  by  two  rings,  united 
by  slender,  elastic  metallic  strips  or  bars. 

Vaginal  Calibrators. 

These  are  instruments  for  the  determination  of  the  degree  of  relaxation 
of  the  vaginal  outlet.  The  necessary  appliance  may  consist  of  a  truncated 
cone  or  some  form  of  dilating  blades. 

Kelly's  Vaginal  Calibrator,  as  outlined  in  figure  1017,  comprises  two 
slender  arms  of  the  non-crossing  variety,  hinged  in  their  centers  with  a 
separable  joint.  Each  arm  is  slightly  curved  outward,  so  that  when  the  tips 


Figure  1017.    Kelly's  Vaginal  Calibrator. 

of  the  blades  at  one  end  are  together,  those  at  the  other  are  separated. 
The  vaginal  end  terminates  in  two  concave  blades  which  project  at  a  right 
angle  witht  he  axis  of  the  instrument.  When  approximated,  they  present 
a  bulbous  form  easy  of  introduction  into  the  vagina.  The  proximal  end  is 
supplied  with  a  graduated  cross-bar  by  means  of  which  the  amount  of  sep- 
aration of  the  blades  may  be  determined.  When  the  blades  are  introduced 
and  opened  as  far  as  possible,  without  the  exercise  of  force,  the  figures  on 
the  scale  measure  the  degree  of  relaxation.  As  a  means  of  diagnosis, 
either  before  or  after  operation,  the  instrument  furnishes  positive  informa- 
tion. 

Uterine  Probes. 

These  consist  of  slender  flexible  rods  attached  to  suitable  handles,  the 
proximal  ends  terminating  in  bulbous  points.  They  are  employed  for 
exploring  the  uterus,  sinuses  and  similar  tracts. 

Owing  to  their  flexibility  under  slight  pressure  and  because  the  point 


Figure  1018.    Sims'  Uterine  Probe. 

will  follow  the  uterine  canal  without  disturbing  the  organ  from  an  even 
abnormal  resting  place,  they  are  preferred  by  some  gynecologists  to  the 
sound. 

Sims'  Uterine  Probe,  as  depicted  by  figure  1018,  consists  of  a  slender 
silver  shaft  about  8  inches  in  length  attached  to  a  handle  from  3  to  4 
inches  in  length.  The  diameter  of  the  shaft,  like  most  patterns  of  sounds, 
decreases  with  its  length,  terminating  at  its  extremity  in  a  bulbous  tip. 
When  in  use,  the  instrument  may  be  curved  to  accord  with  the  supposed 
position  and  shape  of  the  uterine  cavity  and,  if  found  incorrect,  it  may  be 
withdrawn  and  changed  as  often  as  may  be  necessary. 

COLLEGE   OK   OSTEOI 

KK\ 


452 


GYNECOLOGICAL    SURGERY. 


Uterine  Tenacula  and  Tenaculum  Forceps. 

These  differ  slightly  from  the  patterns  described  in  the  chapter  devoted 
to  laparotomy  and  shown  by  figures  950  and  951,  in  being  heavier  and  hav- 
ing shorter  and  stronger  hooks.  They  are  employed  to  draw  the  uterus 
nearer  to  the  vaginal  outlet  and  to  steady  it,  either  for  inspection  or  oper- 
ation. They  may  be  either  single  or  double,  the  latter  being  usually  known 
as  tenaculum  forceps. 

Dudley's  Tenaculum  differs  from  the  older  pattern  of  Sims,  in  being 
heavier  and  in  the  shape  of  the  hook.  Its  hook-shaped  point  is  straight 


Q3H333HD 
Figure  1019.    Dudley's  Tenaculum. 

and  bent  at  slightly  more  than  a  right  angle  with  the  handle  line.  This 
pattern,  as  illustrated  by  figure  1019,  is  heavy  enough  to  withstand  the 
application  of  considerable  force  without  danger  of  bending  the  shaft. 
Besides  being  useful  in  general  uterine  manipulation,  it  may  be  used, 
because  of  its  short  hook,  to  advantage  in  tucking-in  the  pouting  edges  of 
wound  margins  when  the  latter  are  being  sutured. 

Kelly's  Tenaculum,  as  depicted  by  figure  1020,  furnishes  a  handle  that 
affords  a  firm  yet  comfortable  grip.      The  inner  surface,  that  is,  the  one 


Figure  1020.    Kelly's  Tenaculum. 

toward  which  the  point  is  turned,  consists  of  a  series  of  depressions,  and 
while  these  corrugations  are  not  sharp  enough  to  prevent  easy  cleaning, 
they  present  such  a  number  of  projections  that  a  good  contact  with  the 
hand  is  assured.  The  tip  of  the  handle  is  curved  in  the  form  of  a  blunt 
liook  that  may  be  advantageously  used  for  many  purposes. 

Tenaculum  Forceps  are  preferred  by  some  operators  to  plain  tenacula 
"because  they  secure  a  grasp  not  liable  to  slip,  and  being  supplied  with  han- 


Figure  1021.    Ball  s  Tenaculum  Forceps. 


dies  of  the  scissors  pattern,  they  are  not  only  more  easy  to  hold  but  they  fur- 
nish a  better  control  over  the  parts  to  be  manipulated.  Many  designs  are 
adapted  for  intra-uterine  traction,  in  which  case  they  may  form  a  double 
diverging  tenaculum.  They  may  also  be  employed  to  spread  apart  the  lips 
of  a  lacerated  cervix.  Those  of  the  latter  pattern  are  particularly  useful  in 
cases  where  the  tissues  of  the  cervix  are  of  a  friable  nature. 

Ball's  Tenaculum  Forceps  consist  of  two  tenacula,  each  terminating 
in  a  looped  or  scissors  handle  and  provided  with  means  by  which  they  may 
be  locked  together,  forming  a  forceps.  By  closing  the  instrument  until 
the  hooks  rest  side  by  side  or  one  upon,  the  other,  the  instrument  may  be 


TENACULUM    FORCEPS. 


453 


introduced  through  the  cervix,  after  which,  by  compressing  the  handles,  a 
double  diverging  tenaculum  is  formed  by  means  of  which  efficient  control 
of  the  uterus  may  be  obtained.  The  blades  may  be  separated  when  desired, 
and  each  used  as  a  single  tenaculum.  As  drawn  for  figure  1021,  they  are 
usually  about  9  inches  in  length,  somewhat  slender,  the  hooked  portion 
being  at  a  right  angle  with  the  shaft. 


Figure  1022.     Skene's  Tenaculum  Forceps. 


Skene's  Tenaculum  Forceps,  well  traced  by  figure  1022,  are  about  9 
inches  in  length,  hinged  near  the  center  and  terminating  in  heavy  curved 
points.  When  closed,  the  loop  formed  by  the  two  points  is  egg-shaped  and 
about  5  millimeters  in  diameter.  As  the  hooks  cross  at  the  point  of  meet- 
ing, a  stop  is  provided  that  the  instrument  may  not  be  injured  by  undue 
pressure  on  the  handles.  A  single  catch  serves  to  retain  the  hold  of  the 
instrument  until  its  release  is  desired. 


Figure  1023.    Wylie's  Tenaculum  Forceps. 


Wylie's  Tenaculum  Forceps  are  probably  the  heaviest  of  this  class  of 
instruments.  They  are  about  10  inches  in  length  and  closely  resemble 
volsellum  forceps  in  general  construction.  One  blade  terminates  in  a 
single  round  hook-shaped  point,  the  opposite  having  two  small  hooks,  the 
three  interlocking.  As  defined  by  figure  1023,  it  is  provided  with  a 
ratchet  catch. 


Figure  1024.    Newman's  Tenaculum  Forceps. 

Newman's  Tenaculum  Forceps,  as  set  forth  in  figure  1024,  do  not  differ 
materially  from  many  of  the  old-fashioned  bullet  forceps  with  which  all 
are  familiar.  It  is,  however,  of  stronger  construction  and  is  provided  with 
a  ratchet  with  numerous  catches,  that  the  instrument  may  be  accommo- 
dated to  tissues  of  varying  thicknesses. 


454 


GYNECOLOGICAL    SURGERY. 

Volsellum  Forceps. 


These,  as  previously  described  on  page  423,  are  employed  to  grasp  and 
draw  forward  the  uterus,  to  engage  and  hold  small  tumors  and  parts 
requiring  incision  or  excision.  They  are  used  in  cases  necessitating  an 
instrument  heavier  than  a  tenaculum. 

Jackson's  Volsellum  Forceps  are  among  the  smallest  of  their  class.  As 
shown  by  figure  1025,  they  are  only  7  inches  in  length  with  slender  blades 


Jackson's  Volsellum  Forceps. 


Figure  1025. 


spread 


an  inch. 


terminating  in  two  small  hooks  having  a 
They  are  adapted  for  delicate  dissections. 

Small  French  Volsellum  Forceps  differ  from  the  last  described  in  being 
heavier,  with  blades  curved  on  the  edge  and  provided  with  longer  hooks 
having  a  spread  of  about  %  of  an  inch.  As  they  are  only  about  6  inches 


Figure  1026.    Small  French  Volsellum  Forceps. 


in  length,  they  are  particularly  adapted  for  handling  small  tumors.     They 

are  exhibited  by  figure  1026,  a  heavier  pattern  being  shown  by  figure  945. 

Byford's  Small  Volsellum  Forceps,   as  represented  by  figure    1027,  are 

provided  with  three  prongs,  thus  affording  a  firm  grip,  particularly  when 


Figure  1027. 


Byford's  Small  Volsellum 
Forceps. 


used  in  grasping  tissues  of  a  friable  nature.  The  instrument  is  7  inches  in 
length  with  straight  blades,  the  spread  of  the  hooks  being  about  T5F  of  an 
inch. 

Dressing  Forceps. 

These,  as  previously  described  on  page  423,  are  required  in  examinations 
for  holding  cotton  or  gauze  to  absorb  or  wipe  away  secretions  and  dis- 
charges and  for  making  applications. 


Byford's  Uterine  Dressing  Forceps, 


Figure  102& 


Byford's  Uterine  Dressing  Forceps  are  somewhat  slender  in  form, 
about  9  inches  in  length  and  with  handles,  as  depicted  by  figure  1028,  slightly 
bent  near  the  proximal  ends.  The  jaws  are  about  i  %  inches  in  length, 


DRESSING    FORCEPS. 


455 


and  the  inner  surfaces  exhibit  a  slight  depression,  extending  nearly  the  full 
length,  giving  the  face  or  contact  portion  a  somewhat  cup-like  appearance. 
Transverse  serrations  extend  the  full  length  of  the  jaw,  while  an  oval 
fenestra  passing  through  both  blades  permits  the  use  of  the  instrument  as 
a  thread  or  ligature  carrier. 


Figure  105U.    Allen  s  Dressing  Forceps. 


Allen's  Uterine  Dressing  Forceps,  as  portrayed  by  figure  1029,  are  straight 
forceps  about  9  inches  in  length,  provided  with  jaws  similar  to  those  last 
described.  They  may  be  procured  with  or  without  a  catch  handle. 

Bozeman's  Dressing  Forceps  are  generally  considered  superior  to  any 
others  of  this  class.  As  set  forth  by  figure  1030,  they  are  constructed  with 
a  double  curve  and  provided  with  a  catch  handle.  The  jaws  are  long,  the 
grasping  portion  being  about  i  inch  in  length  and  transversely  serrated. 


Bozeman  s  Dressing  Forceps. 


Figure  1030. 


As  this  instrument  has  a  double  curve,  in  order  that  the  handles  may  not 
rest  within  the  line  of  vision,  the  surgeon  should  be  particular  regarding 
the  side  of  the  forceps  next  to  the  hand.  It  is  not  uncommon  to  see  oper- 
ators using  forceps  of  this  character  with  the  face  or  upper  portion  turned 
outward.  This  not  only  fails  to  secure  the  advantages  of  the  curved 
handle,  but  places  the  hand  in  a  more  awkward  position  than  when 
straight  forceps  are  used. 

Emmet's  Dressing  Forceps,  as  indicated  by  figure  1031,  are  of  the  spring 
forceps  type  with  serrated  jaws.       They  are  usually  about  8*4  inches  in 


Figure  1031.      Emmet's  Uterine  Dressing  Forceps. 

length  and  provided  with  a  sliding  catch  controlled  by  a  thumb  movement. 
The  latter  is  so  arranged  that  the  instrument  may  be  used  with  or  without 
the  locking  device. 

Uterine  Swabs  or  Applicators. 

These  may  consist  of  a  slender,  flattened  wire,  a  plain  rod  or  one  having 
a  coarse  thread  cut  on  its  distal  end.  The  latter,  if  twisted  while  its  threaded 
portion  is  pressed  within  a  mass  of  cotton,  will  wind  the  fibers  into  a  ball 


Figure  1032.    Emmet's  Plain  Applicator. 


that  will  be  thus  firmly  attached.       They  are  employed  for  absorbing  or 
wiping  away  discharges. 

Emmet's   Plain   Applicator  consists  of  a  flattened  wire   attached  to   a 


456  GYNECOLOGICAL    SURGERY. 

handle  similar  to  that  delineated  in  figure  1032.     They  are  usually  about 
9  or  10  inches  in  length.     They  may  be  of  silver,  aluminum  or  copper. 
Sims'  Swab  consists  of  a  hard  rubber  handle  and  rod  terminating  in  an 


Figure  1033.    Sims'  Swab. 

enlarged  head,   upon  the  external  surface  of  which  a  thread  is  cut,  as 
sketched  in  figure  1033.     The  usual  length  is  about  9  inches. 

Mucus  Syringes. 

These  consist  of  long  nozzle  piston  syringes  employed  to  remove  ropy 
discharges  that  may  occlude  the  uterine  canal. 

Thomas'  Mucus  Syringe  is  an  ordinary  hard  rubber  piston  syringe  pro- 
vided with  a  straight  uterine  pipe  about  4  inches  in  length,  to  the  point  of 
which,  as  explained  by  figure  1034,  a  hard  rubber  cylinder  about  2^  inches  in 


Figure  1034.    Thomas'  Mucus  Syringe. 

length  and  ^  inch  in  diameter  is  firmly  attached.  By  pressing  the  extrem- 
ity of  the  cylinder  against  the  mouth  of  the  uterus  and  withdrawing  the 
piston,  the  instrument  will  usually  remove  by  suction  any  excess  of  dis- 
charges contained  within  the  canal.  The  usual  size  of  syringe  employed  is 
about  2  ounces. 

Mucus  Curettes. 

These  are  employed  for  the  same  purpose  as  mucus  syringes  and  are 
preferred  by  some  operators  because  less  complicated  and  more  easily 
sterilized. 

Duke's  Mucus  Curette  consists  of  a  handle  and  shank  terminating  in 
two  long  slender  wire  loops  one  within  and  at  right  angles  to  the  other, 


Figure  1035.    Duke's  Mucus  Curette. 

the  whole,  as  outlined  by  figure  1035,  having  an  extreme  breadth  of  about 
10  centimeters.  This  instrument  is  employed  for  removing  mucus 
from  the  cervical  canal,  by  introducing  and  rotating  the  instrument,  thus 
loosening  the  deposit. 

Uterine  Dilatation. 

The  cervical  canal  may  be  dilated  by  either  rapid  or  gradual  methods. 

Rapid  Dilatation. 

Rapid  dilatation  consists  in  the  employment  at  one  sitting  of  force  or 
means  sufficient  to  secure  the  desired  enlargement  of  the  external  os  and 
cervical  canal.  As  this  method  necessitates  more  or  less  trauma  to  the 
tissues,  it  should  be  employed  only  under  strict  aseptic  technique.  Rapid 
dilatation  may  be  secured  by  expanding  dilators,  conical  dilators,  and 
incision. 

Expanding  Dilators  may  be  subdivided  into  two  classes:  metal,  the 
distal  ends  of  which  are  horizontally  split  or  divided  and  provided  with 


UTERINE    DILATATION. 


457 


mechanism  by  means  of  which  the  two  halves  may  be  caused  to  diverge  or 
spread  apart;  and  bags  of  soft  rubber  or  other  collapsible  material  so  con- 
structed that  after  being  introduced  into  the  cervical  canal,  they  may  be 
filled  with  fluid  and  dilated  to  the  required  size. 

Metal  Expanding  Dilators  are  required  in  most  cases  where  dense,  firm 
tissue  is  encountered.  They  may  be  procured  in  a  multiplicity  of  designs. 
From  this  vast  number  we  will  select  only  such  patterns  as  represent 
typical  forms. 

Atlee's  Uterine  Dilator  consists  of  a  scissors-shaped  instrument  termina- 
ting in  two  long  slender  blades,  the  inner  surfaces  of  which  are  flat  and  the 


external  convex,  and  so  shaped  that  when  closed,  they  form  a  well-rounded, 
slender,  conical  extremity.  As  shown  by  figure  1036,  instruments  of  this 
class  differ  from  forceps  in  that  the  blades  do  not  cross.  The  pressing  of 
the  handles  together  separates  instead  of  closing  the  tips.  A  stop  or  set 
pin  is  provided  in  the  curved  handle  that  the  instrument  may  be  locked 
when  the  blades  are  closed.  In  this  condition,  this  dilator  resembles  a  sound 
and  may  be  introduced  almost  as  readily.  The  instrument  is  slightly 
curved  on  the  edge  and  is  usually  from  10  to  n  inches  in  length.  This 


Figure  1037.    Wylie's  Uterine  Dilator. 

pattern  is  frequently  employed  in  cases  of  constriction,  in  order  to  prepare 
the  way  for  a  larger  and  heavier  instrument. 

Wylie's  Uterine  Dilator,  as  detailed  by  figure  1037,  consists  of  a  strongly 
built  instrument  provided  with  handles  of  the  bone  forceps  pattern,  termina- 
ting in  heavy  beaks  curved  on  the  flat  and  slightly  corrugated  on  their  lat- 
eral surfaces.  An  enlargement  in  the  blades  in  the  form  of  a  ring,  set  about 


Figure  1038.    Leonard's  Straight  Dilator. 

3  inches  from  the  extremity,  marks  the  point  beyond  which  the  instrument 
should  not  be  introduced.  The  blades  are  curved  near  their  tips  and  are 
thus  easier  of  introduction,  particularly  in  cases  of  flexion. 

Leonard's  Straight  Dilator  differs  from  Wylie's  pattern,  principally  be- 
cause the  blades  expand  in  a  more  nearly  parallel  direction  and  to  a  greater 
extent.  By  consulting  figure  1038,  it  will  be  seen  that  the  outer  or  contact 
surface  is  roughly  corrugated,  so  that  the  instrument  may  not  slip  from 
position  when  in  use.  A  lateral  cross-bar  connects  the  handles,  while  re- 


458 


GYNECOLOGICAL     SURGERY. 


taining  and  fly  nuts  enable  the  operator  to  secure  dilatation  by  means  of  screw 
power,  or  to  retain  the  instrument  in  position  when  the  amount  of  dilata- 
tion desired  is  secured. 

Wathen's  Uterine  Dilator  is  of  still  heavier  construction  than  the  one 
last  described.  As  illustrated  by  figure  1039,  the  handles  are  bent  down- 
ward in  order  that  the  hand  of  the  operator  may  not  obstruct  the  operating 
field.  The  blades  are  short  and  sharply  corrugated  that  the  instrument 
may  not  slip  from  its  position  when  in  use,  A  threaded  cross-bar  extends 
from  one  handle  to  the  other,  provided  with  a  stop  and  forcing  nut. 


Figure  1039.    Wathen  s  Uterine  Dilator. 

The  former  is  located  between  the  handles,  and  as  the  bar  is  graduated, 
this  may  be  so  set  that  excessive  dilatation  may  be  prevented.  The  blades  of 
the  instrument  may  be  kept  separated  to  any  desired  extent  by  means  of  a  fly 
nut  placed  on  the  cross-bar,  external  to  the  handles.  This  is  of  advantage  in 
cases  where  it  is  necessary  to  allow  the  instrument  to  remain  in  position  for 
some  time. 


Figure  1040.     Goodell's  Uterine  Dilator. 

Goodell's  Uterine  Dilator  differs  materially  from  those  before  described, 
in  that  the  blades  expand  parallel  to  each  other.  As  illustrated  by  figure 
1040,  the  handles,  cross-bar  and  fly  nut  are  not  unlike  the  pattern  of  Wa- 
then, previously  described.  The  blades  of  this  instrument,  however,  are 
hinged  at  a  point  about  4^  or  5  inches  from  their  extremities.  Attached 
to  these  hinges  at  one  end,  and  sliding  in  slots  cut  through  the  bars  at  the 
other,  is  a  plain  actuating  cross-bar  joint,  by  means  of  which  lateral  parallel 
separation  of  the  blades  is  secured.  The  advantage  of  this  instrument  is 
that  it  secures  dilatation  of  the  external  os  without  greater  dilatation  of  the 
internal  parts.  The  lateral  surfaces  of  the  blades  are  corrugated  to  pre- 
vent slipping.  The  instrument  is  strong  and  mechanically  well  calculated 
to  perform  the  work  required.  The  blades  are  usually  about  5  millimeters 
in  diameter  and  about  7  millimeters  in  their  larger  part.  Kelly  advises  the 
use  of  a  dilator  of  this  pattern,  but  without  the  cross-bar  and  fly  nut. 


UTERINE    DILATATION. 


459 


Collapsible  Bag  Dilators  are  usually  constructed  of  soft  rubber,  though 
gut  and  similar  substances  are  sometimes  employed.  They  consist  of  a 
bag  provided  with  an  inlet  pipe,  by  means  of  which  it  may  not  only  be  filled, 
but  usually  enlarged  by  forced  injections  of  fluid.  Air  will  answer  for  this 
purpose,  but  owing  to  its  elasticity  it  is  less  powerful,  and  by  its  diffusibility 
more  difficult  to  hold  under  pressure  than  water.  Sterile  water  only  should 
be  used,  so  that  in  cases  of  accidental  bursting,  infection  may  not  result. 

Barnes'  Bag  Dilators  consist  of  soft  rubber  bags,  shaped  somewhat  like 
a  violin,  and  terminating  at  one  end  in  a  rubber  tiibe  12  to  15  inches  in 
length.  As  drawn  in  figure  1041,  a  small  pocket  is  shown  attached  to  one 


Figure  1W1.      Barnes'  Bag  Dilators. 


side  of  the  bag  near  the  distal  end.  This  pocket  is  utilized  to  receive  the 
bulbous  point  of  a  uterine  sound  or  similar  instrument,  by  means  of  which 
the  bag  is  crowded  or  forced  into  the  canal.  As  these  bags  can  not  be  intro- 
duced into  the  normal  cervix  uteri,  they  are  usually  preceded  by  the  use 
of  sponge  tents  or  other  forms  of  dilators.  Usually  they  vary  from  ^  to 
i  yz  inches  in  diameter,  while  their  length  is  about  3  inches.  After  being 
introduced,  the  dilator  and  contained  fluid  may  be  kept  in  place  by  some 
form  of  cut-off,  or  as  is  more  often  the  case,  the  tube  may  be  turned  back 
upon  itself  and  the  doubled  portion  tied  with  a  cord. 


Figure  1042.    Emmet's  Collapsible  Bag  Dilator. 


Emmet's  Collapsible  Bag  Dilator,  as  displayed  by  figure  1042,  differs 
from  the  pattern  of  Barnes'  in  being  more  easy  of  introduction.  A  central 
soft  rubber  tube  attachment  to  both  ends  of  the  bag  extends  through  the 
center.  The  distal  end  of  this  tube  is  closed,  enabling  the  operator  to 
introduce  a  sound  or  probe,  thus  stiffening  the  instrument  and  furnishing  a 
means  for  pushing  it  into  place.  To  further  facilitate  its  passage  through 
the  cervical  canal,  the  corners  of  the  distal  end  are  turned  in,  thus  giving 
to  the  bag  a  conical  form.  On  expansion,  these  corners  become  everted  and 
give  to  the  bag  the  same  form  as  the  pattern  of  Barnes.  They  are  usually 
constructed  in  three  sizes  similar  to  the  pattern  of  Barnes. 


460 


GYNECOLOGICAL    SURGERY. 


Conical  Dilators  consist  of  rods,  or  handles,  terminating  in  conical 
points,  from  2  y2  to  3  inches  in  length.  Usually  they  are  designed  in  sets, 
the  points  or  conical  portions  so  constructed  that  each  succeeding  number 
in  its  distal  half  is  of  about  the  same  size  as  the  preceding  one  at  its  base 
or  larger  part. 

Hanks'  Conical  Dilator,  as  it  appears  in  figure  1043,  consists  of  a  central 
shaft  terminating  at  each  end  in  a  conical  point,  2  ^  inches  in  length  and 


Figure  1043.    Hanks'  Conical  Dilator. 


slightly  curved.  They  are  usually  manufactured  in  sets  of  six  pieces,  thus 
supplying  twelve  different  sizes,  varying  from  Nos.  13  to  30,  French  scale. 
Byford's  Conical  Dilator  differs  from  the  pattern  of  Hanks,  in  that  it  is 
manufactured  from  metal  and  is  more  sharply  curved.  As  they  are  con- 
structed from  block  tin,  they  may  readily  be  curved  to  any  desired  shape. 
A  slight  projection,  zyz  inches  from  each  end,  marks  the  normal  uterine 


J 


Figure  1044.    Byford's  Conical  Dilator. 

depth.  As  usually  manufactured,  and  represented  by  figure  1044,  they 
are  about  1 2  inches  in  length,  embracing  sizes  which  in  their  larger  parts 
vary  from  14  to  32,  French  scale,  three  pieces  forming  a  set. 

Peaslee's  Uterine  Dilators  consist  of  a  set  of  five  conical  dilators,  each 
connecting  by  a  screw  thread  with  a  universal  handle,  the  total  length,  in- 


Figure  1045.     Peaslee's  Uterine  Dilators. 


eluding  the  handle,  being  about  10  inches.  Usually  they  are  constructed 
from  brass,  steel  or  some  other  firm  metal.  As  described  by  figure  1045, 
their  diameters  through  the  largest  part  of  the  bulb  are  8,  10,  12,  15  and  18 
millimeters  respectively.  Owing  to  their  compact  form  they  may  be  carried 
in  small  space. 


UTERINE    DILATATION. 


461 


Hanks'  Large  Dilators  consist  of  a  double-curved  shank  about  5  inches 
in  length,  to  which  are  attached  at  each  end  conical  egg-shaped  bulbs,  vary- 
ing in  length  from  2^  to  3  inches,  and  in  diameter  from  ^  to  1%  inches. 
Ten  of  the  dilators,  with  one  handle,  as  detailed  by  figure  1046,  form  a 
complete  set.  They  are  intended  for  use  in  securing  extreme  dilatation. 


Figure  1046.    Hanks'  Large  Dilators. 

Incision. 

Incision  of  the  cervical  canal,  for  purposes  of  enlargement,  may  be 
secured  by  the  use  of  scalpels,  special  kinds  of  scissors,  supplemented  with 
tenacula,  volsellum  forceps,  etc. 

Gradual  Dilatation. 

This  may  be  obtained  by  introducing  into  the  cervical  canal  substances 
that  expand  upon  absorption  of  fluids.  Instruments  of  this  class  are  called 
tents. 

Besides  being  employed  as  uterine  dilators,  they  are  sometimes  used  to 
enlarge  fistulous  tracks.  Owing  to  the  great  danger  of  infection,  tents  (now 
but  little  used)  should  not  be  employed  in  the  uterine  cavity  except  in 
contact  with  unbroken  mucous  surfaces.  All  may  and  should  be  sterilized 


Figure  1047.    Sponge  Tent  with  Thread  Passing 
Through  from  End  to  End. 


Figure  1048.    Curved  Sponge  Tent. 


before  use.  For  this  we  recommend  the  dry  heat  system  of  Boeckmann, 
as  described  on  page  160.  They  may  be  manufactured  from  sponge,  sea- 
tangle,  tupelo,  elm  bark,  etc. 

Sponge  Tents  are  small  cones  formed  of  sponge  saturated  with  mucilagi- 
nous fluid,  compressed  while  moist  and  hardened  by  evaporation.  They 
are  usually  manufactured  from  ordinary  reef  sponges.  They  should  be  con- 
structed from  a  single  piece  by  selecting  one  of  proper  size  and  cutting  it 
into  conical  form,  preserving  as  much  of  the  external  surface  as  possible. 
The  sponge  is  then  transfixed  through  the  center  from  base  to  apex  with  a 
stiff,  slender,  sharp-pointed  wire.  It  is  next  dipped  in  a  solution,  after 
which  it  is  compressed  by  tightly  winding  it  with  a  strong  cord,  commenc- 
ing at  the  larger  end  and  continuing  the  wrapping  until  the  sponge  is  en- 
tirely closed.  They  should  be  shortened  during  the  wrapping  by  pressing 
the  mass  together  from  end  to  end.  After  the  cord  has  been  secured,  the 
wire  should  be  withdrawn  and  the  tent  dried  in  the  sun,  or  other  suitable 


462 


GYNECOLOGICAL    SURGERY. 


place.  When  nearly  hard,  they  may  be  curved  to  any  desired  shape.  The 
roughened  surface  produced  by  the  layers  of  cord  is  considered  an  advantage, 
as  it  prevents  the  tent  from  slipping.  The  better  qualities  are  provided 
with  a  thread  extending  through  the  wire  perforation  from  end  to  end,  thus 
avoiding  the  dangers  of  leaving  a  portion  within  the  canal.  This  feature 
is  shown  by  figure  1047. 

Sponge  Tents,  as  shown  by  figures  1048  and  1049,  may  be  procured  in  almost 
any  size.  Usually  they  vary  from  7  to  10  millimeters  in  diameter,  and  from 
\Y^  to  2^  inches  in  length.  They  are  either  plain  or  waxed,  the  latter 
being  either  straight  or  curved. 

Sea  Tangle  Tents  are  manufactured  from  dried  laminaria  digitata,  an 
aquatic  plant,  common  along  the  Atlantic  coast.  The  texture  of  the  dried 
material  is  firm,  and  when  carefully  shaped  and  polished  presents  a  smooth 


Figure  1019.    Sponge  Tent.  Figure  1050.    Sea  Tangle  Tent. 

surface.  They  are  usually  straight,  as  portrayed  by  figure  1050,  but  they 
may  be  rendered  soft  by  boiling  in  an  antiseptic  fluid,  in  which  condition 
they  may  be  curved  as  desired,  and  on  cooling,  the  shape  will  be  retained. 
They  are  said  to  possess  more  dilating  power  than  tupelo,  but  less  than 
sponge.  They  are,  however,  much  slower  in  their  action  than  either. 
They  are  usually  about  2^  inches  in  length,  and  from  3  to  9  millimeters  in 
diameter.  They  may  be  procured  either  solid  or  hollow.  The  latter  were 
intended  to  meet  a  demand  which  no  doubt  arose  from  the  impression  that 
a  solid  tent  by  completely  obstructing  the  canal,  prevented  the  escape  of 
fluids  from  the  body  of  the  uterus.  An  examination  of  several  hollow  tents, 


Figure  1051.    Tupelo  Tents. 


after  introduction  and  dilatation,  demonstrated  that  the  opening  through 
the  tent  soon  becomes  clogged,  and  that  the  supposed  advantage  does  not 
exist. 

Tupelo  Tents  are  manufactured  from  the  compressed  root  of  the  tupelo 
tree  (nyssa  aquatica),  a  native  of  the  southern  states.  They  were  first 
employed  by  Sussdorff,  who  found  them  a  valuable  material  from  which  to 
manufacture  tents.  The  material  is  light,  spongy,  easily  worked  and 
obtainable  in  large  quantities.  Ordinarily  when  dilated  they  increase  to 
about  twice  their  bulk.  As  outlined  by  figure  1051,  they  are  .usually  about 
2^/2  inches  in  length,  and  vary  in  diameter  from  3  to  7  millimeters.  Like 
the  sea  tangle  tents  before  referred  to,  they  may  be  procured  solid  or  hol- 
low. As  they  are  rigid  and  inflexible, '  they  are  found  only  in  a  straight 
variety. 

Slippery  Elm  Tents  are  manufactured  from  the  bark  of  the  ulmus 
fulva  by  cementing  together  various  layers  and  submitting  them  to  high 
pressure.  Elm  bark  has  long  been  recognized  by  the  medical  profession  as 


URETHRAL    AND    BLADDER    EXAMINATIONS.  4(33 

an  excellent  material  for  this  purpose,  as  is  demonstrated  by  the  fact  that 
tents  whittled  from  the  ordinary  commercial  bark  have  been  recommended 
by  various  authors  for  many  years.  Their  non-irritant  and  demulcent  prop- 
erties render  them  applicable  in  many  cases  where  tents  from  other  material 
could  not  be  tolerated.  On  being  moistened  they  are  quickly  covered  by 
a  self-exuding  mucilaginous  coat  which  thickens  as  absorption  increases, 
protecting  inflamed  or  ulcerated  mucous  surfaces.  As  described  by  figure 
1052,  they  are  usually  about  2^  inches  in  length,  and  vary  in  size  from  3 
to  10  millimeters  in  diameter.  Larger  sizes,  even  to  those  of  yz  to  ^  of  an 
inch  in  diameter,  may  be  also  procured.  The  latter  are  usually  called  elm 
plugs,  and  are  either  solid  or  hollow. 


URETHRAL  AND  VESICAL  EXAMINATIONS. 

As  examinations  of  the  urethra  or  bladder  require  in  many  cases  dupli- 
cate sets  of  instruments,  both  are  here  included  in  our  list.  According  to 
Kelly,  to  whom  we  are  largely  indebted  for  the  invention  and  perfection  of 
the  necessary  appliances,  the  following  embraces  the  required  instruments : 

Light  and  reflector  for  illumination. 

Female  catheter  for  withdrawal  of  urine. 

Dilator  for  enlarging  and  measuring  urethra. 

Specula  for  inspection  of  urethra  or  bladder. 

Vesical  evacuator  or  syringe  for  removing  urine. 

Applicator. 

Cotton  holding  forceps  for  mopping  out  bladder. 

Light  and  Reflectors. 

Reflectors,  with  the  necessary  lighting  apparatus,  will  be  fully  described 
in  the  chapter  devoted  to  throat  instruments.  According  to  Kelly,  a  re- 
flector with  a  focus  of  1 2  inches  is  to  be  preferred. 

Female  Catheters. 

Female  catheters  are  employed  for  evacuating  the  bladder  contents 
previous  to  an  operation,  those  of  small  caliber  being  advised.  They 


Figure  1053.    Ordinary  Metal  Female  Catheter  with  Double  Eye. 

consist  of  slender  tubes  of  glass,  metal  or  other  material,  closed  and  usually 
slightly  curved  at  their  tips,  and  provided  with  lateral  openings  for  the 
flow  of  urine. 

Ordinary  Metal  Female  Catheters  are  provided  with  lateral  openings 
for  the  entrance  of  urine,  one  being  about  ^  inch  to  the  rear  of  the  tip, 
the  other  upon  the  opposite  side,  about  ^(  inch  to  the  rear.  A  ring,  as  dis- 
played in  figure  1053,  is  placed  at  the  proximal  end  and  on  the  under  side 


Figure  1054.    Metal  Female  Catheter  with  Small  Eyes. 

of  the  catheter  to  denote  the  direction  of  the  curve  when  the  instrument  is 
in  situ,  and  to  furnish  means  by  which  the  instrument  may  be  retained  in 
position  with  cord  or  tape.  The  usual  length  is  about  5  inches,  with  diam- 
eters varying  from  4  to  6  millimeters. 


464 


GYNECOLOGICAL    SURGERY. 


Metal  Female  Catheters  with  Small  Eyes  do  not  differ  from  those  last 
described,  excepting  that  instead  of  the  two  lateral  openings  they  are  pro- 
vided with  10  to  15  small  perforations,  distributed  upon  all  sides  of  the 
tube.  This  feature  is  detailed  in  figure  1054,  and  is  an  advantage  in  cases 
where  the  catheter  must  remain  in  situ  for  a  considerable  length  of  time, 
because  when  large  eyes  or  openings  are  brought  in  contact  with  mucous 
surfaces,  the  latter  not  infrequently  become  impacted  in  the  openings,  not 
only  occluding  them  but  furnishing  a  source  of  irritation  or  inflammation. 

Glass  Female  Catheters  consist  of  double-curved  glass  tubes  similar  in 
construction  to  the  first  pattern  referred  to.  They  vary  in  shape,  that 
shown  by  figure  1055  being  one  of  the  more  common.  They  may  be  ster- 


Figure  1055.    Glass  Female  Catheter. 


ilized  by  boiling  and  stored  in  carbolic  acid  or  boracic  acid  solution.  They 
are  safe  if  perfect  (without  crack)  when  introduced.  They  are  generally 
preferred  for  hospital  use,  not  only  because  they  can  be  bought  cheaply, 
but  because  they  are  considered  more  cleanly. 

Urethral  Dilators. 

These  are  employed  for  enlarging  the  lumen  of  the  urethral  canal. 
They  are  usually  expansible  or  constructed  in  conical  form.  When  conical 
and  calibrated,  they  serve  to  measure  the  orifice,  thus  enabling  the  surgeon 
to  select  a  speculum  of  corresponding  size. 

Kelly's  Urethral  Dilator  and  Calibrator  consists  of  a  solid  metallic  cone 
about  3  inches  in  length,  the  base  terminating  in  a  bulbous  handle.  At 


Figure  1056.    Kelly's  Dilator  and  Calibrator. 

its  apex  the  diameter  is  about  3  millimeters,  while  at  its  base  it  is  about  16 
millimeters.  The  markings,  sketched  in  figure  1056,  upon  one  side  of  the 
instrument  denote  its  diameter  at  each  point. 

Byford's  Urethral  Dilator  consists  of  two  slender  slightly  curved  cones 
united  at  their  bases  and  forming  a  sigmoid-shaped  instrument,  as  appears 


Figure  1057.    Byford's  Urethral  Dilator. 


in  figure  1057.  The  extremity  of  the  smaller  dilator  is  somewhat  smaller 
than  the  base  of  the  larger  one.  Owing  to  the  slight  resistance  offered  by  the 
female  urethra,  this  single  instrument  may  be  used  successfully  in  the  great 
majority  of  cases.  The  diameters  vary  from  Nos.  10  to  50,  French  scale. 


URETHRAL    AND    VESICAL    EXAMINATIONS. 


465 


Urethral  or  Vesical  Specula. 

Specula,  sometimes  called  urethroscopes  or  endoscopes,  are  necessary 
not  only  to  conduct  the  reflected  light  into  the  bladder  so  as  to  form  a  win- 
dow for  visual  examination,  but  to  maintain  the  dilated  condition  of  the 
urethra.  They  may  be  tubular  or  have  expanding  blades,  the  latter  being 
now  little  employed  except  for  urethral  examinations. 

Usually  they  consist  of  an  endoscopic  tube,  with  or  without  obturator, 
longer  than  the  normal  urethra.  The  vesical  end  should  be  slightly 


Figure  1058.    Kelly's  Bladder  Speculum. 


Figure  1059.    Caro's  Urethral  Speculum. 


turned  in,  that  it  may  fit  closely  against  the  obturator.  If  the  plan  of 
Kelly  be  followed,  one  should  be  selected  of  the  size  indicated  by  the 
calibrator.  In  the  absence  of  regular  instruments,  tin  tubes  may  be  used 
with  or  without  the  aid  of  head  mirrors. 

Kelly's  Bladder  Speculum,  as  exhibited  by  figure  1058,  consists  of  a 
metallic  tube,  which  may  be  procured  in  two  sizes,  the  smaller  3^,  the 
larger  4^  inches  in  length,  the  proximal  end  of  which  is  funnel-shaped 
and  to  which  is  attached  a  handle  for  manipulation.  Each  is  provided  with 


Figure  1060.      Sampson's 
Urethral  Speculum. 


Figure  1061.    Sims'  Urethral  Speculum 


an  obturator  consisting  of  an  acorn-shaped  point  mounted  upon  a  slender 
rod  attached  to  a  handle  which  projects  from  the  rear  of  the  funnel  previ- 
ously referred  to. 

The  obturator  assists  in  the  introduction  of  the  instrument  and  should 
be  removed  after  the  latter  is  in  position.  They  are  manufactured  in  a 
series  of  sizes,  each  being  marked  with  the  number  of  millimeters  repre- 
senting the  diameter  of  the  tube.  These  numbers  range  from  5  to  20, 
though  Kelly  advises  that  the  specialist  provide  himself  with  half  sizes,  as 
follows:  Nos.  6^,  7^,  8^,  9^,  10^,  and  n^.  The  sizes  below  No.  12 

30 


466 


GYNECOLOGICAL    SURGERY. 


are  used  for  examination,  and  those  above  to  secure  a  wide  lumen  in  oper- 
ations within  the  bladder. 

Caro's  Urethral  Speculum,  as  explained  by  figure  1059,  consists  of  two 
trough-shaped  blades  with  angular-bent  handles,  the  latter  hinged  at  their 
proximal  extremity.  When  closed,  the  instrument  presents  the  shape  of  a 
tube  somewhat  flattened,  conical  at  its  distal  end  and  consequently  easy  of 
introduction.  After  being  dilated,  the  expansion  may  be  maintained  by 
means  of  a  set  screw.  Usually  they  are  from  5  to  8  millimeters  in  diameter 
near  the  base  and  from  2  to  3^  inches  in  length. 

Sampson's  Urethral  Speculum,  as  depicted  by  figure  1060,  consists  of  a 
pair  of  blades  similar  to  those  last  described,  except  that  the  handles  are 


Figure  1062.    Pratt's  Urethral  Speculum. 

bent  at  a  right  angle  with  the  blades  and  caused  to  diverge  or  expand  by 
means  of  a  toggle-joint  controlled  by  screw  power.  The  blades  are  fenes- 
trated,  usually  about  8  millimeters  in  diameter  and  2^  inches  in  length. 

Sims'  Urethral  Speculum  consists  of  two  wire  fenestrated  blades  bent 
downward  at  right  angles,  controlled  by  long  handles.  A  spring  tends  to 
keep  the  blades  closed  while  a  sliding  link,  as  defined  in  figure  1061, 
enables  the  operator  to  keep  the  blades  expanded  to  any  desired  degree. 
This  pattern,  when  manufactured  from  steel,  -forms  one  of  the  best  of  the 
bi-valve  specula. 

Pratt's  Urethral  Speculum  is  one  of  the  most  simple  of  the  effective 
patterns.  As  set  forth  by  figure  1062,  the  handle  and  blades  are  single 
forgings,  the  latter  being  grooved  lengthwise,  so  that  when  closed,  the  yare 
tubular.  Dilatation  is  produced  by  pressure  on  the  handles,  while  a  set 
screw  fixes  and  maintains  the  instrument  in  an  expanded  form.  This 
instrument  is  often  used  as  a  dilator,  and  is  satisfactory  for  this  purpose. 

Vesical  Suction  Syringes. 

These  are  used  to  withdraw  urine  not  removed  by  natural  voiding  or 
catheterism,  and  to  remove  accumulating  urine  during  a  prolonged  exami- 
nation. If  the  amount  be  trifling,  however,  it  may  be  taken  up  by  absorp- 


Figure  1063.    Kelly's  Vesical  Suction  Syringe. 

tion,  by  using  small  cotton  balls,  held  by  a  slender  mouse-tooth  forceps.  A 
substitute  for  this  instrument  may  be  made  by  attaching  a  piece  of  soft,  rub- 
ber tubing  to  the  suction  end  of  a  bulb  syringe. 

Kelly's  Vesical  Suction  Syringe,  as  delineated  by  figure  1063,  consists  of 
a  small  bulb  of  from  i  to  2  ounces  capacity,  connecting  by  means  of  a  rub- 
ber hose  with  a  small  hollow  perforated  ball.  On  compressing  the  bulb 
and  passing  the  evacuating  tip  into  the  residual  urine,  by  releasing  the 


URETHRAL    AND    VESICAL    EXAMINATIONS. 


467 


bulb  pressure,    the  urine  may  be  sucked  or  drawn  up  into  the  instrument. 
The  diameter  of  the  terminal  bulb  should  not  exceed  5  millimeters. 

Applicators. 

Applicators  for  use  in  the  urethra  and  bladder  are  required  as  cotton 
carriers,  etc.  They  may  be  used  as  swabs,  thus  answering  a  two-fold  pur- 
pose. 


THUAX-GHEENE-CO. 


Figure  1064.    Kelly's  Vesical  Applicator. 


Kelly's  Vesical  Applicator,  as  represented  by  figure  1064,  consists  of  a 
slender  rod  about  6  inches  in  length,  one  third  of  its  length  being  bent  at  an 
angle  to  form  a  handle.  The  distal  end  is  flattened. 

Kelly's  Urethral  Cocaine  Applicator,  as  pictured  in  figure  1065,  is  a 
slender  tapering  rod  about  3^  inches  in  length,  the  distal  end  of  which  is 


Figure  1065.     Kelly's  Urethral  Cocaine  Applicator. 

slotted  that  it  may  be  used  to  engage  and  wind  into  a  ball  a  small  cotton 
mass.  As  the  instrument  is  of  delicate  and  slender  construction,  it  is  well 
adapted  for  making  applications  to  the  female  urethra. 

Vesical  Cotton  Holding  Forceps. 

Slender  mouse-tooth  forceps  are  employed  as  cotton  holders  for  swab- 
bing out  or  absorbing  any  residual  urine  with  balls  of  cotton.  They  are 
intended  for  use  only  where  minute  quantities  are  to  be  removed.  The  in- 
strument must  be  slender  enough  to  be  operated  through  a  vesical  speculum. 

Kelly's  Vesical  Cotton  Holding  Forceps,  as  shown  in  figure  1066,  are  of  the 
plain  spring  forceps  type,  9^  inches  in  length,  one-half  this  distance  being 
made  up  of  two  slender  blades  of  such  diameter  that  they  may  be  readily 


Figure  1066.    Kelly's  Vesical  Cotton  Holding  Forceps. 

passed  through  the  speculum  previously  referred  to.  One  of  the  blades  ter- 
minates in  two  teeth  and  the  other  in  one,  the  three  interlocking  so  closely 
that  they  will  firmly  hold  small  balls  of  cotton.  That  the  cotton  may  be 
securely  held,  the  teeth  should  be  slightly  recurved 


Figure  1067.    Byford's  Vesical  Cotton  Holding  Forceps. 


Byford's  Vesical  Cotton  Holding  Forceps,  as  illustrated  by  figure  1067, 
iffer  from  those  of  Kelly  only  in  that  the  handle  portion  is  curved  at  an 
angle  to  enable  the  operator  to  better  direct  the  forceps  by  sight. 


468  GYNECOLOGICAL  SURGERY. 

URETERAL  AND  RENAL  EXAMINATIONS. 

Instruments  employed  for  examination  of  the  female  ureters  and  kidneys 
may  be  classified  as  those  for  catheterism  of  the  ureters  and  for  dilating  or 
exploring  the  ureters. 

Catheterism. 

This  is  usually  undertaken  to  secure  a  sample  of  urine  direct  from  the 
kidney  for  examination.  That  this  sample  may  not  be  contaminated,  it  is 
essential  that  not  only  the  catheter  or  other  collector  be  sterile  but  that  the 
urine  be  conducted  through  sterile  channels  and  deposited  in  a  sterile  recep- 
tacle. The  instruments  necessary  consist  of 

Cystoscopic  set,  described  in  the  previous  section. 

Ureteral  searcher  for  locating  mouths  of  ureters. 

Goniometer  for  determining  ureteral  angles. 

Catheters  or  other  means  for  collecting  ureteral  urine. 

Receptacles  for  collected  urine. 

Urine  segregator. 
The  latter  is  in  many  cases  the  only  instrument  required. 

Ureteral  Searchers. 

These  are  employed  for  locating  the  opening  of  the  ureter  previous  to 
the  introduction  of  the  catheter,  for  exploring  sinuses,  etc.  Usually  they 
are  slender  probe-like  instruments,  so  constructed  that  they  can  be  operated 
through  a  speculum. 


Figure  1068.    Kelly's  Ureteral  Searcher. 

Kelly's  Ureteral  Searcher,  as  represented  by  figure  1068,  is  a  slender 
metallic  probe,  about  7  inches  in  length,  terminating  in  a  handle  25^  inches 
in  length,  bent  at  an  angle  of  120°.  The  probe  is  quite  slender  near  its  dis- 
tal extremity  (not  to  exceed  a  millimeter  in  diameter),  and  terminates  in  a 
small  bulbous  tip. 

Vesical  Goniometers. 

This  is  an  instrument  to  measure  the  angle  made  by  the  long  axis  of  the 
urethra  with  a  line  drawn  from  the  internal  urethral  orifice  to  the  mouth  of 
the  ureter. 


Figure  1069.    Kelly's  Goniometer. 


URETERAL    AND    RENAL    EXAMINATIONS. 


469 


Kelly's  Goniometer,  as  displayed  in  figure  1069,  consists  of  a  slender 
metallic  probe,  provided  with  a  flattened  handle,  the  latter  bent  downward 
that  in  holding  it  the  hand  of  the  operator  may  not  obstruct  the  field  of 
vision.  A  graduated  quadrant,  hinged  at  its  apex,  as  shown  in  the  figure, 
enables  the  operator  to  read  off  the  angle  as  soon  as  the  mouth  of  the  ure- 
ter is  located. 

Ureteral  and  Renal  Catheters. 

Ureteral  catheters  are  slender  and  usually  somewhat  curved  at  their  tips. 
They  may  be  either  rigid  or  flexible.  Renal  catheters  are  flexible,  and 
are  usually  of  elastic  web. 

Rigid  Ureteral  Catheters  are  of  two  varieties,  one  intended  for  use 
through  a  speculum,  the  other  in  cases  where  a  general  anesthetic  is  not 
employed  and  the  urethra  is  not  dilated. 

Those  to  be  used  through  specula  have  no  handle,  a  small  ring  upon 
one  side  determining  the  direction  of  the  curved  tip.  Those  used  in  the 
urethra  are  usually  constructed  with  an  enlargement  or  handle,  and  sup- 
plied with  an  obturator,  by  which  the  tube  may  be  kept  closed  until  it  has 
been  introduced  into  the  ureter.  Several  openings  are  provided  near  the 
distal  end  that  the  flow  of  urine  may  be  unimpeded. 


Figure  1070.    Kelly's  Metal  Ureteral  Catheter. 

Kelly's  Ureteral  Catheter,  as  illustrated  by  figure  1070,  consists  of  a 
slender  tube  about  2^  millimeters  in  diameter  and  6  inches  in  length,  ter- 
minating in  a  slender  conical  point,  slightly  curved.  The  distal  end  is  sup- 
plied with  several  small  oval  openings.  The  proximal  end  is  provided 
with  a  shoulder  to  which  a  rubber  hose  may  be  attached.  This  pattern  is 
useful  in  cases  where  there  is  a  stricture  of  the  ureter  at  its  lower  end, 
where  the  canal  is  tortuous  or  where  for  any  reason  a  flexible  instrument 
cannot  be  passed. 


Figure  1071. 


Pawlik's  Ureteral  Catheter,  as  displayed  by  figure  1071,  consists  of  a 
tube  of  the  same  length  as  the  one  last  above  described  and  terminating  in 
a  small  tip.  It  differs  in  being  constructed  with  an  enlargement  or  handle 
by  means  of  which  it  may  be  manipulated.  As  a  rule,  catheters  of  this 
character  are  introduced  without  the  use  of  either  a  speculum  or  a  general 
anesthetic.  In  such  cases  it  is  customary  to  evacuate  the  contents  of  the 
bladder  and  replace  it  with  a  sterile  aniline  solution.  Through  this  fluid 
the  catheter  with  the  plug  in  the  proximal  end  is  passed.  After  its  intro- 
duction into  the  supposed  ureter,  if  the  plug  be  withdrawn  and  colored  fluid 
escape,  it  is  evident  that  the  ureter  has  not  been  penetrated. 

Two  of  these  instruments  may  be  used  simultaneously,  thus  enabling 
the  surgeon  to  compare  separately  the  urine  from  each  kidney. 

Flexible  Ureteral  and  Renal  Catheters  are  made  of  fine  elastic  silk  web, 
similar  to  those  described  on  page  535.  They  differ  from  each  other  only 


470  GYNECOLOGICAL    SURGERY. 

in  length,  the  former  being  usually  about  12  and  the  latter  about  20  inches 
in  length.  They  are  preferred  by  many  operators  because,  as  they  readily 
follow  the  curves  of  the  ureters,  there  is  little  danger  of  injury  to  mucous 
surfaces.  They  may  generally  be  passed  directly  into  the  kidneys,  and 
when  in  position,  offer  no  resistance  if  the  position  of  the  patient  be 
changed.  They  must  be  of  the  finest  possible  construction  and  finished 
with  eyes  carefully  formed.  Generally  a  wire  stylet  is  necessary  to  stiffen 
them  during  introduction.  After  use  they  should  be  thoroughly  sterilized 
and  carefully  dried  by  three  or  four  days'  exposure  in  a  warm  place. 

Like  all  other  catheters,  a  description  of  which  will  be  found  on  page 
535,  they  should  be  curved  only  when  warm.  They  are  not  suitable  for  use 
in  the  ureters  if  the  surface  be  cracked  or  inclined  to  scale.  Kelly  advises 


Figure  1072.    Kelly's  Elastic  Web  Ureteral  and  Renal  Catheters. 

that  they  be  stored  each  in  a  straight  glass  tube,  the  ends  of  which  are 
plugged  with  cotton.  For  transportation  he  employs  a  canvas  roll-up 
pouch,  divided  into  compartments,  each  holding  one  tube. 

Kelly's  Elastic  Web  Ureteral  and  Renal  Catheters  are  made  of  silk  web, 
finely  coated  with  elastic  varnish  and  highly  polished.  Both  lengths,  as 
before  mentioned,  may  usually  be  procured  in  diameters  of  i^,  2,  2^,  2^, 
2^  and  3  millimeters.  Figure  1072  shows  a  short  section  of  the  vesical  end 
of  the  instrument. 

Kelly's  Bladder  Speculum,  with  obliquely  cut  end,  as  delineated  by 
figure  1073,  differs  from  the  regular  pattern,  shown  by  figure  1058,  only  in 
the  shape  of  its  vesical  end.  the  under  surface  of  which  is  prolonged.  The 


Figure  1073.    Kelly's  Bladder  Speculum  with  End  Cut  Obliquely. 

extreme  length  of  the  tube  is  4  inches,  and  its  diameter  10  millimeters.  It 
is  intended  for  use  when  only  a  few  drops  of  urine  from  the  suspected 
ureter  is  required  for  examination.  It  may  be  used  with  the  patient  in 
the  knee-breast  position,  the  long  lip  of  the  speculum  being  passed  under 
the  mouth  of  the  uterer  until  a  jet  of  urine  is  expelled,  which  may  be 
caught  from  the  outer  lip  in  any  small  vessel.  The  speculum  requires  care- 
ful sterilization  before  use. 


Figure  1074.    Kelly's  Ureteral  Urine  Conductor. 


Kelly's  Ureteral  Urine  Conductor,  as  will  be  seen  by  consulting  figure 
1074,  consists  of  a  tube  provided  with  a  handle  at  one  end,  the  other  being 
enlarged  into  a  cup  with  its  open  face  directed  upward.  The  instrument 
is  of  such  length  and  the  cup  of  such  size  that  it  may  be  passed  through  a 


URETERAL    AND    RENAL    EXAMINATIONS. 


471 


No.  10  vesical  speculum.     By  holding  the  cup  under  the  ureteral  mouth 
any  escaping  urine  may  be  conducted  to  the  prepared  receptacle. 

Ureteral  Urine  Receptacle. 

These  may  be  of  any  form.  A  test  tube  block  is  not  an  essential  but 
is  a  convenient  appliance.  It  serves  to  hold  a  test  tube  in  position  while 
the  catheterized  urine  is  being  conducted  into  it. 


Figure  1075.    Kelly's  Test  Tube  Block 

Kelly's  Test  Tube  Block,  as  appears  in  figure  1075,  consists  of  a  solid 
wood  base,  provided  with  one  or  two  holes,  or  wells,  in  which  test  tubes  may 
be  securely  held  while  the  catheterized  urine  is  being  conducted  into  them. 
With  this  appliance  the  accidental  overturning  of  a  test  tube  is  avoided. 

Harris'  Urine  Segregator,  as  illustrated  in  figure  1076,  consists  of  a 
double  channel  catheter  with  which  urine  from  each  kidney  may  be  secured 
without  danger  of  admixture.  The  instrument  is  composed  of  two  slender 


Figure  1076.    Harris'  Urine  Segregator. 


catheters,  each  independent,  included  in  an  oval  or  flattened  tube  and  con- 
nected with  a  small  vacuum  bottle  into  which  the  collected  urine  is  stored 
and  conducted.  The  main  portion  of  the  catheters  and  containing  sheath 
is  straight,  the  former  being  curved  downward  at  both  extremities.  Each 
catheter  is  so  constructed  that  it  may  be  separately  revolved  on  its  longitu- 
dinal axis,  within  the  sheath.  The  distal  ends  of  the  catheters  are  slightly 
sigmoid  in  shape,  each  presenting  the  appearance  of  one-half  of  a  shaft  split 


472  GYNECOLOGICAL    SURGERY. 

by  longitudinal  section.  When  the  tips  are  curved  upward  for  introduction, 
the  two  flat  surfaces  rest  face  to  face,  so  that  the  instrument  is  about  the 
same  size  as  the  main  body  or  sheath.  These  tips  are  provided  near  their 
extremities  with  lateral  openings  in  a  line  with  the  flat  inner  surfaces, 
while  the  latter  are  covered  with  numerous  perforations. 

A  long  curved  lever  terminating  in  a  flattened  ovoid  tip  is  employed  to 
raise  the  bladder  wall  between  the  diverging  vesical  ends,  and  thus  form  a 
watershed,  so  that  with  the  patient  in  the  lithotomy  position  the  urine  from 
each  ureter  passes  at  once  into  the  catheter  tip  upon  that  side  of  the  eleva- 
tion. The  main  shaft  of  the  lever  occupies  a  lower  plane  than  the  ovoid  tip. 
A  detachable  forked  arm  depends  from  the  catheter  sheath,  and  to  this  the 
lever  is  attached  by  means  of  the  pin  shown  in  the  illustration.  When  in 
position,  by  introduction  of  the  lever  into  the  vagina  of  the  female  or  the 
rectum  of  the  male,  it  is  held  in  place  by  the  spiral  spring  shown  in  the 
illustration.  The  proximal  catheter  endings  are  curved  downward  and  bi- 
furcated, one  set  of  the  forked  extensions  projecting  backward  in  a  line 
with  the  main  body  of  the  instrument.  These  are  employed  for  irrigation, 
when  necessary.  During  the  withdrawal  of  urine  they  are  connected  with  a 
short  piece  of  rubber  hose  so  sharply  bent  upon  itself  as  to  close  the  lumen, 
thus  preventing  the  passage  of  urine  from  one  catheter  to  the  other.  The 
proximal  catheter  tips  are  each  connected  with  a  separate  vacuum  bottle. 
The  latter  are  of  the  regular  pattern,  with  rubber  stoppers  and  inlet  and  out- 
let tubes.  By  means  of  a  bifurcated  tube  they  are  attached  to  an  ordinary 
suction  bulb  by  which  an  exhaust  force  may  be  imparted  to  the  catheters. 
The  straight  portion  of  the  shaft  is  20  centimeters  in  length  and  by  gradu- 
ations on  its  outer  surface  the  extent  of  introduction  may  be  determined. 

After  passing  the  vesical  portion  within  the  bladder,  the  proximal  cathe- 
ter tips  should  each  be  rotated  outward  until  the  subtended  angle,  one  with 
the  other,  is  from  120°  to  140°,  in  which  position  they  may  be  maintained 
by  the  small  spiral  spring  shown  in  the  illustration.  It  is  evident  that  the 
vesical  tips  will  each  bear  the  same  relation  to  the  other  as  do  the  outer 
ones,  and  if  properly  within  the  bladder,  they  should  rest  outside  of  and 
immediately  under  the  ureteral  orifices.  Previous  to  rotating  the  tips,  the 
lever  should  be  introduced  directly  in  the  median  line  until  the  perforation 
in  the  lever  shaft  is  opposite  the  opening  in  the  forked  arm,  where  it  may 
be  secured  by  a  pin  provided  for  the  purpose.  By  this  it  should  be  plainly 
seen  that  the  catheter  tips  do  not  pass  into  the  ureters,  but  on  the  contrary, 
when  in  proper  position,  rest  against  the  posterior  bladder  wall  close  under 
the  ureteral  orifices. 

Dilatation  and  Exploration  of  the  Ureters. 

Ureteral  stricture  may  be  located,  explored  and  ofttimes  relieved  by  the 
use  of  suitable  bougies.  These  will  be  found  useful  in  procedures  involv- 
ing tissues  intimately  associated  with  the  track  of  the  ureter.  In  such 
cases  it  is  advisable  to  permanently  locate  the  ureter  by  the  introduction 
of  a  long  urethro-ureteral  bougie.  In  most  cases  the  elastic  web  catheter, 
shown  by  figure  1072,  may  be  substituted  for  the  bougie. 

Kelly's  Ureteral  Bougies  are  made  from  gum  elastic,  metal  or  hard  rub- 
ber, and  vary  in  size  from  i^  to  3  millimeters  in  diameter,  the  serial  num- 
bers differing  from  each  other  in  diameters  of  %  millimeters,  as  described 
by  figure  1077.  They  are  usually  manufactured  in  two  lengths,  14  and  20 
inches  each.  Special  bougies,  with  bulbous  enlargements  7  millimeters 
back  of  the  point,  are  useful  in  locating  and  dilating  strictures.  They  are 


UTERINE    CURETTAGE. 


473 


usually  2  millimeters,  with  bulbs  varying  from  2^  to  4  millimeters  in 
diameter.  Those  of  elastic  web  do  not  differ  from  the  catheters  shown  by 
figure  1072,  excepting  in  the  omission  of  the  eyes.  Hard  rubber  bougies 
are  advised  for  use  except  in  cases  of  hysterectomy,  when  on  account  of 
danger  of  breakage  the  elastic  web  patterns  should  be  used. 


Figure  1077.    Kelly's  Ureteral  Bougies. 


UTERINE  CURETTAGE. 

Uterine  curettage  consists  in  the  removal  of  foreign  growths,  adven- 
titious tissues  or  mucous  membrane  from  the  uterine  body  by  scraping  or 
tearing  by  means  of  spoon,  scoop  or  loop-shaped  instruments  called  curettes. 

Curettes. 

The  instrument  is  either  spoon-shaped  or  fenestrated.  Its  edge  may  be 
blunt  or  sharp.  The  shanks  may  be  of  soft  or  tempered  steel  or  of  copper. 
The  first  may  be  curved  as  wanted,  before  introduction.  The  latter,  while 
they  serve  to  remove  some  forms  of  diseased  tissue  and  loose  foreign  sub- 
stances, will  not  injure  sound  structures. 

The  handle  should  be  serrated  or  otherwise  marked  upon  one  side,  so 
that  the  surgeon  may  at  all  times  know  with  which  face  he  is  operating. 
Not  a  few  patterns  are  double,  having  each  end  formed  into  a  curette,  while 
others  are  manufactured  with  tubular  handles  that  irrigation  may  be 
simultaneously  practiced. 

As  curettement  is  often  followed  by  packing  the  uterus  with  gauze  or 
similar  substance,  a  description  of  the  necessary  instruments  will  be  in- 
cluded under  this  head. 


i 


Figure  1078.    Thomas'  Dull  Curette. 

Thomas'  Dull  Curette,  as  shown  in  figure  1078,  consists  of  a  flexible 
metal  shank,  terminating  in  an  ovoid  loop,  about  8  millimeters  wide.  One 
side  of  the  loop  is  constructed  with  angular  edges,  the  other  edge  being 
round  or  wire-like.  This  instrument  thus  offers  two  surfaces  for  curetting 
purposes,  either  of  which  may  be  brought  into  use  by  curving  the  shank  in 
the  required  direction. 


Figure  1079.    Sims'  Sharp  Curette. 


Sims'  Sharp  Curette  is  a  thin  loop  of  steel  attached  to  a  somewhat  slen- 
der and  flexible  shank.  The  loop,  as  exhibited  in  figure  1079,  is  curved  on 
the  flat,  and  presents  a  cutting  edge  of  almost  knife-like  sharpness. 

Wylie's  Curettes,  as  indicated  by  figure  1080,  differ  from  the  pattern  of 
Sims,  last  described,  in  being  constructed  with  a  rigid  shank  and  a  loop  or 


474 


GYNECOLOGICAL    SURGERY. 


fenestra  somewhat  flaring  in  form  and  with  a  still  sharper  edge.  They  are 
manufactured  in  three  sizes,  the  extreme  breadth  of  each  being  8,  9  and  10 
millimeters,  respectively. 


Figure  1080.    Wylie's  Curette. 


Kelly's  Curette,  as  exhibited  in  figure  1081,  consists  of  a  long,  rigid, 
straight  shank,  terminating  in  an  oval  bowl,  slightly  curved  on  the  flat.  The 
depression  is  about  7  millimeters  in  breadth  by  35  in  length,  and  3  in  depth. 
The  margins  are  somewhat  sharp  and  well  designed  for  removing  abnormal 


Figure  1081.    Kelly's  Curette. 

growths.  Owing  to  the  well-rounded  outer  surface  of  the  instrument  it  is 
calculated  to  avoid  injury  to  sound  tissues.  The  entire  length  of  the  instru- 
ment is  usually  10  or  n  inches. 


Figure  1082.    Simon's  Sharp  Curette. 

Simon's  Sharp  Curette,  as  illustrated  in  figure  1082,  is  a  solid  steel 
spoon-shaped  instrument,  presenting  an  oval  concavity  with  sharp  edges. 
They  are  usually  manufactured  in  three  sizes,  8,  10  and  12  millimeters  in 
breadth,  respectively. 


Figure  1083.    Byford's  Curettes. 


Byford's  Curettes,  as  detailed  in  figure  1083,  are  constructed  with  flex- 
ible shanks,  terminating  in  short,  broad  ovoid  loops,  one  surface  of  which 
is  well  rounded  with  little  more  denuding  power  than  a  large  wire,  while 


TRU  AX— GREENE-CO 


Figure  1084.     Holbrook's  Douche  Curette. 


the  inner  or  cup-shaped  surface  is  dull,  presenting  no  more  cutting  surface 
than  the  back  of  a  table  knife.  They  are  manufactured  in  three  sizes,  9, 
12  and  15  millimeters  in  breadth. 


UTERINE    PACKERS. 


475 


Holbrook's  Douche  Curette  has  a  tiibular  shank  that  may  be  connected 
with  an  irrigator.  Each  handle  is  supplied  with  two  curettes  almost  iden- 
tical in  pattern  with  Simon's,  figure  1082,  one  being  8  and  the  other  10  mil- 
limeters in  breadth.  The  opening  through  the  handle  and  shaft  finds  an 
outlet  in  the  rear  and  bottom  of  the  spoon,  as  shown  in  figure  1084. 


Figure  1085.     Hoag's  Set  of  Curettes. 

Hoag's  Curettes,  as  shown  by  figure  1085,  consist  of  a  finger  clamp,  to 
which  by  slots  and  pins,  bayonet-shaped  curettes  of  various  patterns  may 
be  attached.  These  instruments  are  practically  the  same  as  elongations  of 
the  finger  nail,  and  are  preferred  by  many  operators  because  the  sense  of 
touch  is  acute  and  the  consequent  dangers  of  injury  by  the  curette  avoided. 
The  thimble-shaped  band  may  be  made  to  conform  to  the  size  of  the  finger. 
Its  adjustment  should  be  such  that  the  bayonet  groove  in  the  shank  should 
rest  against  the  tip  of  the  finger. 

The  curettes  are  of  five  varieties,  Thomas'  dull,  Sims'  sharp,  Simon's, 
Byford's  and  a  plain,  dull  scoop  pattern. 

Packers. 

Instruments  for  packing  the  uterus  with  gauze  or  other  substance  may  be 
of  various  kinds,  among  the  more  common  of  which  are  forceps,  forks  and 
grooved  rods. 


Figure  1086.    Lenneker's  Packing  Forceps. 

Lenneker's  Packing  Forceps,  as  shown  by  figure  1086,  are  of  light  con- 
struction with  long  and  slender  blades,  that  when  closed  resemble  an  ordi- 
nary uterine  sound  in  size  and  shape.  They  are  curved  on  the  flat  and  the 
jaws  are  slightly  roughened  and  have  transverse  serrations.  They  may 
be  usually  found  in  two  lengths,  10  and  12  inches. 

Pratt' s  Packing  Forceps,  as  traced  in  figure  1087,  have  a  double 
curve,  the  handle  turning  downward  and  the  jaws  upward.  The  former 


476  GYNECOLOGICAL    SURGERY. 

have  no  catch,  and  the  latter  are  serrated  with  a  groove  or  gutter  extend- 
ing along  the  inner  faces. 


Figure  1087.    Pratt's  Packing  Forceps. 

Kelly's  Packer,  as  depicted  by  figure  1088,  consists  of  a  miniature  blunt, 
three-pronged  fork.  It  may  be  used  to  advantage  not  only  in  packing 
the  uterus,  but  in  introducing  dressings  into  the  vagina  and  placing  gauze 
drains  in  the  abdomen  or  in  deep  wounds. 


Figure  1088.    Kelly's  Packer. 

Bernays'  Packer,  as  shown  by  figure  1089,  consists  of  a  rod  and  handle, 
the  former  curved  at  its  distal  end,  the  outer  border  of  which  is  furnished 
with  serrations  or  grooves,  the  open  faces  of  which  are  inclined  outward. 


Figure  1089.    Bernays'  Packer. 


OVARIOTOMY  BY  ABDOMINAL    SECTION. 

The  list  of  instruments  should  contain  the  following: 

Minor  operating  list,  pages  270  to  275. 

Laparotomy  list,  page  414. 

Receptacle  for  contents  of  cyst. 

Trocar  for  evacuating  the  fluid  contents  of  cyst. 

Traction  forceps  for  manipulation  of  tumor. 

Sac  forceps  for  withdrawal  of  empty  sac. 

Pedicle  forceps  for  compression  of  pedicle. 

Pedicle  clamp  for  compressing  and  holding  pedicle. 

Transfixion  ligature  carrier. 

Cautery  clamp  for  cauterization  of  pedicle. 

Tenaculum  forceps  for  manipulation  of  small  tumors,  page  452. 

Male  urethral  sound  for  occasional  use  in  breaking  up  adhesions,  figure 

1359- 

Uterine  sound  for  ascertaining  condition  of  uterus,  page  450. 
Curette  for  preparatory  curettage  of  uterus,  page  473. 
Drainage  tubes,  page  427. 
Rubber  ligature  cord. 
Curved  trocar,  figure  1273. 

Ovariotomy  Trocars. 

The  trocar  may  be  either  straight  or  curved,  sharp  or  blunt-pointed, 
and  with  or  without  sac-holding  clamps.  It  is  employed  to  empty  a  cyst 
of  its  fluid  contents,  thus  reducing  the  size  preparatory  to  its  withdrawal 
through  the  abdominal  incision. 


OVARIOTOMY    TROCARS. 


477 


To  prevent  escaping  fluid  from  flowing  back  into  the  abdomen,  trocars 
are  usually  provided  with  a  rubber  hose  attached  to  the  outer  end,  through 
which  the  fluid  may  be  conveyed  to  a  bucket.  Ordinary  trocars  of  small 
caliber  will  be  found  described  on  page  208. 


Figure  1090.    Tait's  Plain  Trocar. 


Tait's  Trocar  consists  of  a  piece  of  metal  tubing  y2  to  i  inch  in  diameter, 
about  1 2  inches  long  and  curved  at  nearly  a  right  angle  at  the  junction  of 
the  outer  and  middle  thirds.  The  penetrating  end  of  the  tube  is  flattened, 
closed,  narrowed,  and  terminates  in  an  oval  point.  The  fluid  escapes 
through  two  large  openings,  as  shown  by  figure  1090. 


Figure  1091.    Kelly's  Glass  Ovarian  Trocar. 


Kelly's  Glass  Ovarian  Trocar,  as  shown  by  figure  1091,  is  designed 
after  the  pattern  of  Tait,  previously  described.  The  proximal  end  is 
curved,  that  it  may  the  better  be  connected  with  a  rubber  escape  tube, 
for  which  a  collar  is  provided.  They  are  constructed  with  large  eyes,  one 
upon  either  side.  Tubes  of  this  character  are  advantageous  because  they 
may  be  easily  sterilized,  the  presence  of  any  dirt  detected,  and  because 
they  are  less  expensive  than  metal  patterns. 


Figure  1092.    Mathieu's  Cyst  Trocar. 


Mathieu's  Trocar,  as  drawn  in  figure  1092,  consists  of  a  short  straight 
tube  from  ^  to  y2  inch  in  diameter,  in  the  lumen  of  which  a  removable 
conical  point  is  mounted  on  a  shaft,  which  terminates  in  a  suitable  handle. 
In  order  to  avoid  the  introduction  of  air  after  the  withdrawal  of  the  per- 
forating point,  a  packing  is  provided  in  the  proximal  end  of  the  tube  in  the 
center  of  which  the  shaft  rests.  This  box  is  supplied  with  leather,  rubber, 
or  other  suitable  packing,  thus  forming  a  close  joint. 

To  prevent  the  closing  or  obstructing  of  the  tube  by  large  clots  or 
tissue  folds,  a  side  opening  is  provided  near  the  point.  Like  the  pattern 
of  Emmet  before  described,  the  canula  is  bifurcated,  so  that  a  rubber  hose 
may  be  attached  to  one  side. 

Tait's  Clamp  Trocar,  as  defined  by  figure  1093,  is  of  large  size  and 
constructed  with  two  spring  clamps,  each  armed  with  long  teeth.  These 


478 


GYNECOLOGICAL    SURGERY. 


are  so  adjusted  that  after  the  introduction  of  the  trocar,  the  walls  of  the 
cyst  may  be  drawn  within  the  grasp  of  the  self-closing  spring  clamps  and 
there  held  until  the  contents  of  the  tumor  are  withdrawn.  This  effectually 
prevents  the  accidental  withdrawal  of  the  trocar  from  the  cyst. 


Figure  1093.    Tait's  Improved  Ovarian  Trocar. 


The  canula  is  usually  manufactured  from  a  metal  tube  \\  of  an  inch 
in  diameter  and  1 2  inches  in  length,  the  perforating  end  being  sharpened 
to  a  point,  like  the  pattern  described  by  figure  1090. 

Traction  Forceps. 

These  are  employed  in  engaging,  holding  and  lifting  large  tumor  masses. 
They  differ  from  volsellum  forceps,  in  being  heavier  and  with  wider  and 
more  extended  grasping  surfaces. 


Figure  1094. 

Williams'  Traction  Forceps,  as  displayed  in  figure  1094,  are  intended 
to  include  large  tumor  masses,  the  distance  between  the  blades,  when 
secured  by  the  first  catch,  being  fully  3  inches.  Successive  catches  are 
provided,  that  any  desired  thickness  of  tumor  tissue  may  be  included 
within  the  grasp  of  the  instrument.  The  blades  each  terminate  in  a  pair 
of  strong  hooks.  The  forceps  are  well  adapted  for  the  manipulation  of 
tumors  of  large  size. 


Billroth's  Large  Traction  Forceps. 


Billroth's  Large  Traction  Forceps,  as  illustrated  by  figure  1095,  repre- 
sents the  largest  instrument  usually  found  among  this  class  of  appliances. 
The  forceps  is  9  inches  in  length  with  a  grasping  surface  i  *4  inches  wide, 
while  the  blades  may  be  distended  so  as  to  include  a  mass  6  inches  in 
diameter.  With  this  forceps,  a  tumor  of  almost  any  size  can  be  success- 
fully handled.  The  blades  are  strong,  well  formed  and  particularly 
adapted  for  this  purpose. 


TRACTION    AND    SAC    FORCEPS. 


Byford's  Traction  Forceps  are  strong  and  heavily  built.  Each  blade  is 
provided  with  two  hooks  or  teeth  that  closely  interlock,  forming  a  firm 
grasp.  The  instrument  is  10  inches  in  length  and  adapted  for  grasping 
tissues  that  require  considerable  force,  such  as  lifting  a  large  tumor  out  of 
the  abdominal  cavity.  It  is  accurately  pictured  by  figure  1096. 


Figure  1096.    Byford's  Traction  Forceps. 

Collins'  Traction  Forceps,  as  traced  in  figure  1097,  are  of  three  pat- 
terns, differing  only  in  the  width  of  their  jaws  and  the  number  of  teeth  in 
each.  They  are  of  strong  construction,  about  10  inches  in  length,  with 
blades  that  open  to  a  good  width,  and  with  a  long  series  of  ratchet  catches, 
by  means  of  which  they  may  be  adapted  to  tissues  of  varying  thicknesses. 
Each  is  provided  with  strong,  slightly  hooked  interlacing  teeth.  The 


Figure  1097.    Collins*  Traction  Forceps. 

smallest  instrument  is  about  i  centimeter  in  extreme  breadth  of  jaw,  with 
four  teeth,  two  upon  either  side.  The  medium  has  six  teeth  with  a  breadth 
of  i^  centimeters,  while  the  largest  has  eight  teeth  and  a  breadth  of  4 
centimeters.  _ 

Sac   Forceps. 

Sac  forceps  are  used  to  grasp  and  hold  a  collapsed  cyst  after  its  contents 
have  been  evacuated.  They  should  present  a  large  grasping  surface  and 
be  provided  with  teeth  or  sharp  serrations  to  prevent  the  soft,  flexible  folds 
of  the  sac  wall  from  slipping  out  of  the  grasp.  Some  operators  advise  the 
use  of  two  forceps  in  operations  for  the  removal  of  large  tumors. 


Figure  1098.    Byford's  Sac  Forceps. 

Byford's  Sac  Forceps  are  among  the  lightest  of  their  class.  They  are  8 
inches  long  and  terminate  in  oval  fenestrated  blades  about  i  inch  in  dia- 
meter, the  inner  margins  of  which  are  finely  serrated.  The  instrument  is 
provided  with  a  ratchet  catch.  The  sac  wall,  when  held  in  this  forceps,  will 
protrude  through  the  fenestrae  of  the  blades,  whose  sharply  serrated  edges 
insure  a  firm  grasp.  It  is  exhibited  by  figure  1098. 


480 


GYNECOLOGICAL    SURGERY. 


Nelaton's  Sac  Forceps  are  of  medium  weight,  about  10  inches  in  length 
and  provided  with  a  ratchet  catch  of  sufficient  extent  to  enable  the  oper- 
ator to  accommodate  the  forceps  to  masses  of  varying  thicknesses.  By 
referring  to  figure  1099  it  will  be  seen  that  the  ends  of  the  blades  are 


Figure  1099.    Nelaton's  Sac  Forceps. 


circular  and  about  ^  of  an  inch  in  diameter,  with  deeply  serrated  faces. 
Four  or  more  long  teeth  are  also  provided  in  each  jaw,  so  adjusted  that 
they  fit  into  openings  provided  in  the  opposite  blade.  These  forceps  sup- 
ply a  grasp  absolutely  secure,  and  as  strong  as  the  enclosed  area  can 
furnish. 


Figure  1100.    Spencer  Wells'  Sac  Forceps. 


Spencer  Wells'  Sac  Forceps,  as  set  forth  in  figure  noo,  are  among  the 
heaviest  of  this  class  of  appliances.  They  are  usually  10*4  inches  in  length 
and  terminate  in  spreading  blades,  each  of  which  ends  in  a  circular  contact 
surface  deeply  grooved  with  sharp  longitudinal  and  transverse  serrations. 
The  peculiar  construction  of  these  jaws  furnishes  a  large  number  of  conical 
teeth,  thus  securing  a  firm  grasp  for  the  instrument. 

Pedicle  Forceps. 


Figure  1101.    Spencer  Wells'  Pedicle  Forceps. 


These  are  designed  for  compressing  the  pedicle,  for  the  double  purpose 
of  temporary  hemostasis  and  the  reduction  of  its  size,  preparatory  to  the 


PEDICLE    FORCEPS. 


481 


application  of  a  ligature.      Various  shapes  and  curves  of  this  instrument 
may  be  required. 

Spencer  Wells'  Pedicle  Forceps  are  of  four  patterns,  as  illustrated  by 
figure  noi ;  namely,  straight,  angular,  half  curved  and  full  curved.  They 
are  usually  about  10  inches  in  length,  of  heavy  design  and  provided 
with  secure  ratchet  catches.  The  contact  surface  of  the  blades  is  about 
2  inches  in  extent,  deeply  corrugated  and  of  such  construction  as  to  meet 
every  requirement  in  cases  where  considerable  force  is  to  be  exerted. 
They  are  applicable  for  holding  the  omentum  where  suturing  is  necessary, 
for  compressing  broad  masses,  to  stop  oozing  of  blood  and  for  closing 
wounds  in  any  of  the  hollow  viscera,  etc. 


Figure  1102.    Spencer  Wells'  T-shaped  Pedicle  Forceps 


iii 

Spencer  Wells'  T-Shaped  Pedicle  Forceps,  as  portrayed  by  figure  1 102, differ 
from  the  patterns  of  Spencer  Wells,  previously  described,  in  that  the  blades 
are  in  T-form  with  compressing  faces  at  right  angles  with  the  handles. 
Usually  the  length  of  the  jaws  is  about  3  inches,  with  a  total  length  of 
forceps  of  about  8  inches. 


Williams'  Half  Curved  Pedicle  Forceps. 


Figure  1104.    Williams'  Full  Curved  Pedicle  Forceps. 

Williams'  Pedicle  Forceps  are  strongly  built,  each  about  10^  inches  in 
length  and  with  corrugated  jaws  4  inches  in  extent.  In  this  latter  partic- 
ular they  differ  materially  from  the  patterns  designed  by  Spencer  Wells. 
In  addition  to  the  ordinary  ratchet  catch,  each  is  provided  with  a  set  screw, 
so  that  when  it  is  necessary  that  they  remain  in  situ  following  the  oper- 
ation, the  blades  may  be  securely  locked  and  accidental  disengagement 
avoided.  Their  curves  and  general  form  are  clearly  set  forth  by  figures 
1 103  and  1 104. 

31 


482 


GYNECOLOGICAL    SURGERY. 


Pedicle  Clamps. 

These  usually  consist  of  some  form  of  clamp  lever,  or  sliding  jaw,  the 
latter  so  constructed  that  it  may  be  closed  by  screw  power.  They  are 
employed  for  pedicle  compression. 

Thomas'  Pedicle  Clamp  consists  of  a  V-shaped  appliance,  hinged  at  its 
apex,  the  distance  between  the  two  arms  being  controlled  by  screw  power. 


Figure  1105.    Thomas'  Pedicle  Clamp. 


Figure  1106.    Spencer  Wells'  Pedicle  Clamp. 


Two  horseshoe-shaped  clamps  of  the  male  and  female  type  project  inward 
from  the  arms,  the  two  being  so  adjusted  as  to  include  a  pedicle  in  their 
grasp.  By  means  of  the  screw  previously  referred  to,  any  amount  of 
compression  may  be  obtained.  The  appliance  is  well  sketched  in  figure 
1105. 

Spencer  Wells'  Pedicle  Clamp,  as  pictured  by  figure  1106,  practically 
consists  of  two  jaws,  one  fixed,  the  other  sliding  or  acting  by  means  of 
screw  power  in  connection  with  the  first.  The  arrangement  is  such  that  a 
pedicle  may  be  included  between  the  two  corrugated  faces,  after  which  any 
desired  amount  of  compression  may  be  secured  by  means  of  the  screw 
attachment. 

Transfixion  Ligature  Carriers. 

These  differ  from  artery  or  aneurysm  ligature  carriers  in  being  heavier, 
longer  and  in  a  greater  variety  of  forms.  Besides  being  applicable  in 
ligating  aneurysms,  they  are  employed  for  carrying  ligatures  around 
pedicles  and  masses,  through  the  broad  ligament  in  vaginal  hysterectomy, 
for  passing  threads  along  or  through  narrow  or  tortuous  tracks,  etc.  They 
should  be  of  sufficient  strength  to  enable  the  operator  to  force  them 
through  broad  stumps  and  other  masses,  where  it  is  desirable  that  a  liga- 
ture shall  only  encompass  a  given  portion  of  the  whole.  They  are  preferred 
to  needles  by  many  operators,  as  their  use  avoids  injury  to  blood-vessels. 

A  Dressing  Forceps  Employed  as  a  Ligature  Carrier  is  shown  by  figure 
1107,  and  is  inserted  at  this  place  to  call  attention  to  a  method  that  may 
be  resorted  to  by  the  surgeon  when  it  is  necessary  to  practice  economy  in 
the  number  of  instruments  employed  in  an  operation.  By  grasping  a  liga- 
ture in  the  serrated  jaws  of  a  plain  spring  dressing  forceps,  both  forceps 
and  ligature  may  be  forced  through  pedicles  and  other  masses  requiring 


TRANSFIXION    LIGATURE    CARRIERS. 


483 


ligation  if  the  instrument  has  moderately  narrow  points.     This  plan  may 
be  employed  to  advantage  in  ligating  the  broad  ligament  and  other  tissues. 


Figure  1107.    Showing  Plain  Dressing  Forceps  Substituted  for 
Ligature  Carrier. 


Figure  1108.    Flemming's  Liga- 
ture Carrier. 


Transfixion  or  Pedicle  Ligature  Carriers  may  be  procured  in  a  great 
variety  of  shapes  and  sizes.  Figure  1109  defines  some  of  the  more  desir- 
able forms.  With  the  exception  of  "A"  all  are  shown  full  size ;  "B,"  "C," 
"D"  and  "E"  are  curved  on  the  flat;  "F"  and  "G"are  both  bent  at  right 
angles  with  the  shaft  and  are  made  "rights  and  lefts,"  and  differ  from 
each  other  only  in  size.  "A"  (shown  at  about  two-thirds  size)  is  also  man- 


Figure  1109.    Transfixion  or  Pedicle  Ligature  Carriers. 

ufactured  "right  and  left,"  but  instead  of  being  bent  at  a  right  angle  it 
is  of  a  helical  or  screw-shaped  pattern.  The  same  shapes  may  also  be 
procured  with  sharp  points. 

Flemming's  Ligature  Carrier  consists  of  a  full-curved  point  provided 
with  a  short  square  shank  that  may  be  readily  grasped  in  the  jaws  of  a 
needle  holder.  This  design  enables  the  surgeon  to  at  once  prepare  a 
carrier,  straight,  curved  or  helical,  and  either  right  or  left,  thus  avoiding 
the  necessity  of  purchasing  a  large  number  of  patterns.  As  outlined  in 
figure  1 108,  they  may  be  procured  in  two  sizes,  large  and  small. 

Deschamp's  Needle  consists  of  a  long  handle  with  strong  shank,  angular- 
curved  in  either  of  two  patterns,  right  or  left.  The  circle  described  by  the 
needle  point  is  usually  about  i  Y^,  inches  in  diameter,  while  the  entire  length 


484 


GYNECOLOGICAL    SURGERY. 


of    the   instrument    is   about   10   inches, 
depicted  in  figure  mo. 


Figure  1110.    Deschamp's  Needles,  Rights  and  Lefts. 


Helical  Needles  differ  from  the  pattern  of  Deschamp  in  being  of  lighter 
construction  and  screw-shaped.      Like  the  pattern  above  referred  to,  they 


Figure  1112.    Helical  Needle. 

may   be    procured    either  right   or  left.      The   design  is   delineated   by 
figure  in 2. 

Cautery  Clamps. 

These  are  necessary  to  hold  a  stump  during  the  application  of  a  cautery. 
They  consist  of  extra  heavy  forceps  provided  with  short  strong  jaws,  the 
blades  being  controlled  by  screw  power. 

Nott's  Cautery  Clamp,  as  illustrated  by  figure  1113,  consists  of  strong 
forceps,  somewhat  in  bayonet  form.  The  jaws  are  very  heavy,  about  T\ 
of  an  inch  in  thickness  by  3^  inches  in  length.  The  contact' surf  ace  of 


Figure  1113.    Nott's  Cautery  Clamp. 


one  is  grooved,  the  lateral  margins  being  serrated,  while  the  opposite  jaw 
is  provided  with  a  tongue  fitting  closely  within  the  groove  before  men- 
tioned. The  proximal  ending  of  one  handle  is  provided  with  a  cross-bar 
and  fly  nut.  By  means  of  a  slot  in  the  end  of  the  opposite  handle,  a  con- 
nection is  made  between  the  blades  so  that  closure  may  be  effected  by 
strong  screw  power. 

Oviatt's  Cautery  Clamp  is  clearly  an  improvement  on  the  older  pattern 
of  Nott.  While  this  design  is  somewhat  lighter  than  the  original  model, 
it  is  still  strong  enough  to  answer  every  purpose.  The  instrument  is  in 
bayonet  form,  the  jaws  being  provided  with  sharply  cut  serrations  extend- 


UTERINE    FIBROIDS.  485 

ing  over  a  surface  of  2^  inches.  The  handles  are  of  the  bone  forceps  type, 
a  cross-bar  connecting  the  two.  This  is  provided  with  a  fly  nut,  by  means 
of  which  compression  by  screw  power  may  be  obtained.  Its  general  form 
is  well  represented  by  figure  1114. 


Figure  1114.    Oviatt's  Cautery  Clamp. 

Ligatures  for  Pedicle  Stumps. 

Ligatures  for  tying  tumor  stumps,  excepting  those  composed  of  rubber 
cord,  do  not  differ  from  the  larger  sizes  described  on  page  317. 

Rubber  Ligature  Cord  is  occasionally  employed  as  a  ligature,  because, 
by  firmly  stretching  the  rubber  and  securely  tying  it  in  place,  it  acts  as  a 
continuous  constrictor.  If  allowed  to  remain  for  a  considerable  length  of 
time,  it  will  force  its  way  through  any  but  the  densest  of  tissues,  usually 
completely  severing  a  stump,  and  this,  too,  without  the  ordinary  risks  of 
hemorrhage.  The  size  best  adapted  for  this  purpose  is  about  No.  17,  French 
scale. 


TREATMENT  OF  UTERINE  FIBROIDS. 

The  surgical  treatment  of  uterine  myoma  usually  necessitates  one  or 
more  of  the  following  procedures :  Curettage,  electrolysis,  vaginal  myomec- 
tomy,  hysterectomy  or  hysterotomy. 

Ourettage. 

This  operation,  which  is  sometimes  employed,  has  been  so  fully 
described  on  page  473  as  not  to  require  further  mention  here. 

Electrolysis. 

This  procedure  for  the  destruction  of  tumor  masses,  etc.,  has  been 
described  on  pages  255  to  257,  to  which  the  reader  is  referred.  Special 
needles  are  sometimes  preferred. 


Figure  1115.    Martin's  Fibroid  Needle. 


Martin's  Fibroid  Needle,  exhibited  in  figure  1115,  consists  of  a  slender, 
flexible,  insulated  shaft,  terminating  in  a  metallic  trocar  point  and  provided 
with  a  handle,  the  whole  so  arranged  that  the  needle  point  may  be  inserted 
into  a  tumor  to  any  desired  depth.  The  handle  is  provided  with  means  for 
attachment  to  the  conducting  wire. 


486  GYNECOLOGICAL    SURGERY. 

Vaginal  Myomectomy. 

Vaginal  myomectomy  may  be  performed  by  several  methods,  each, 
however,  requiring  the  following  general  list  of  instruments  and 
appliances: 

Minor  operating  list,  on  pages  270  to  275. 

Leg  holder,  for  securing  patient,  figures  194  to  197. 

Sims'  speculum,  largest  size  for  exposing  uterus,  figure  991. 

Vaginal  depressors,  for  increasing  size  of  operating  field,  figure  1009. 

Uterine  dilators,  for  enlarging  cervical  canal,  figure  1036. 

Long-handled  scissors,  for  excision  of  tumor  or  attachments,  figure  928 

Compression  forceps,  for  hemorrhage,  figures  938  to  944. 

Pedicle  ligature  carrier,  in  case  ligation  is  necessary,  figure  1109. 

Round  needles,  for  repairs  in  accidental  injury,  figure  983. 

Needle  holder,  figures  753  to  768. 

Packer,  for  filling  tumor  cavity  with  gauze,  etc.,  figure  1086. 

Tenaculum  forceps,  for  manipulation  of  uterus,  figure  1021. 

To  which  should  be  added,  according  to  the  method  of  treatment  adopted, 
selections  from  the  following  lists : 

If  by  simple  avulsion  if  the  tumor  be  quite  small. 

Polypus  forceps,  for  twisting  or  tearing  away  the  mass. 

If  wholly  infra-uterine,  without  adhesions  other  than  the  pedicle. 

Special  volsellum  forceps  for  grasping  or  twisting  off  the  tumor. 

If  by  excision  of  pedicle,  either  one  or  more  of  the  following: 

Curved  scissors,  round-pointed,  for  excision,  figure  928. 

Galvano-cautery  battery  and  handle  with  windlass  and  wire  loop  for 
excision  by  heated  wire,  figure  493. 

Ecraseur. 

Kuechenmeister's  scissors,  where  lateral  incision  of  cervix  is  necessary. 

Myomectomy  forceps,  for  large  intra-uterine  tumors. 

Ligatures  of  large  size,  for  tying  stumps  either  with  or  without  trans- 
fixion, see  page  317. 

If  by  morcellement  or  fragmentation. 

Scissors  with  one  point  sharp  for  detaching  pieces  of  tumor  mass. 

Knife  for  cutting  out  wedge-shape  pieces. 

And  morcellement  forceps,  for  grasping  and  tearing  away  pieces. 

If  by  enucleation. 

Thomas'  spoon  saw,  for  cutting  through  adhesions. 

Plain  enucleator,  for  separation  of  tissues. 

Polypus  Forceps. 

These  are  required  for  the  removal  of  small  pedunculated  tumors  by 
a  simple  avulsion.  They  are  usually  scissors-handled,  and  of  strong  con- 
struction with  jaws  that  will  securely  grasp  small  masses  of  soft  tissues. 


Figure  1116.    Sims'  Polypus  Forceps. 


Sims'  Polypus  Forceps,  as  indicated  by  figure  1116,  is  a  strongly  con- 
structed instrument  from  9  to  10  inches  in  length,  the  inner  surface  of  the 


VOLSELLA — £CRASEURS.  487 

jaws  being  deeply  serrated  and  somewhat  concave,  thus  affording  a  strong 
grip.  It  is  either  straight  or  curved,  both  patterns  being  provided  with 
ratchet  catches. 

Volsellum  Forceps. 

Strong  volsellum  forceps,  with  which  the  tumor  may  be  seized  and 
twisted  on  its  axis  until  its  stump  is  severed  or  torn  from  its  attachments, 
are  sometimes  employed  in  avulsion.  They  differ  from  those  described 
on  page  454,  in  being  heavier  and  having  stronger  jaws. 


Figure  1117.    Jacobs'  Volsellum  Forceps. 

Jacobs'  Volsellum  Forceps  are  particularly  adapted  for  clasping  and 
holding  an  intra-uterine  tumor.  They  are  about  8  inches  in  length, 
straight,  with  blades  of  good  length  slightly  spread,  one  of  which  is  pro- 
vided with  two  and  the  other  with  three  strong,  well- sharpened  teeth  so 
arranged  that  they  will  interlock  when  tightly  closed.  The  forceps  are  pro- 
vided with  three  catches,  as  described  by  figure  1117.  The  instrument  is 
well  rounded  and  can  be  easily  introduced  through  the  cervical  canal. 

Ecraseurs. 

s 

Ecraseurs  consist  of  mechanism  for  shortening  or  drawing  in  a  slip 
noose,  by  means  of  which  any  enclosed  soft  tissues  may  be  strangulated  or 
excised.  Wire,  plain  or  twisted,  or  special  link-loops  are  usually  em- 
ployed. They  are  sometimes  employed  for  severing  tumor  pedicles. 
They  are  constructed  on  two  principles,  screw  power,  lever  and  ratchet. 
Either  of  these  may  be  used  in  connection  with  loops  of  wire  or  chains. 
These  instruments,  which  were  once  largely  employed,  have  been  generally 
abandoned  because  of  the  time  required  for  adjustment  and  operation,  and 
by  reason  of  the  danger  of  including  the  uterine  wall  or  other  tissues,  the 
removal  of  which  is  not  desired  in  the  loop. 


Figure  1118.    Smith's  Straight  Wire  ^craseur. 

Smith's  Ecraseur  consists  of  a  slotted  shaft  attached  to  a  strong  steel 
shank,  the  latter  terminating  in  a  fenestrated  head  through  which  a  wire 
loop  is  caused  to  actuate,  and  a  screw  operated  by  a  handle,  upon  which 
a  traveling  nut  may  be  moved  back  and  forth,  as  the  screw  is  turned  to  the 
right  or  left.  To  this  traveling  nut,  both  ends  of  the  wire  forming  the  loop 
are  attached,  so  that  the  size  of  the  latter  may  be  increased  or  diminished  at 
will.  They  may  be  obtained  either  straight  or  curved;  the  former  is 
shown  in  figure  1118. 


GYNECOLOGICAL    SURGERY. 


Skene's  ifcraseur  is  of  the  curved  variety  and  differs  from  the  pattern  of 
Smith,  only  in  being  heavier  and  in  the  method  of  clasping  the  ends  of 
the  wire  loop.  In  this  pattern  two  curved  jaws  or  clamps  are  provided, 
with  convex  surfaces  closely  fitting  into  concave  receptacles,  as  illustrated 
by  figure  1119.  These  surfaces  are  slightly  serrated  and  can  be  opened 


Figure  1119.    Skene's  Ecraseur. 

or  .closed  by  a  set  screw.  The  evident  design  of  the  author  was  to  prevent 
the  untying  or  slipping  of  the  wires  from  the  traveling  nut  ordinarily 
used,  an  accident  not  uncommon  in  the  old  style  patterns. 

Cervical  Scissors. 

These  differ  from  ordinary  patterns,  in  being  provided  with  teeth,  by 
means  of  which  the  tissues  included  in  the  bite  may  be  firmly  held  between 
the  blades  during  excision. 


Figure  1120.    Kuechenmeister's  Scissors. 

Kuechenmeister's  Scissors,  as  pictured  by  figure  1120,  are  constructed 
particularly  for  lateral  incision  of  the  cervix.  The 'under  blade  is  straight 
and  somewhat  sharply  pointed,  that  it  may  be  readily  passed  into  the 
cervical  canal.  The  upper  and  outer  blade  is  not  only  longer  than  the  first, 
but  terminates  in  a  sharp  tooth  or  hook,  projecting  inward  at  nearly  a  right 
angle  with  the  cutting  edge. 

This  instrument  is  intended  to  overcome  the  difficulties  encountered  in 
attempting  to  open  the  cervix  with  ordinary  scissors.  The  tissues,  being 
firm  and  tough,  are  frequently  crowded  back  by  the  biting  action  of  the 
cutting  blades.  With  this  instrument,  the  tissues  may  be  firmly  held  and 
a  complete  incision  made  possible. 

Myomectomy  Forceps. 

These  usually  consist  of  a  scissors-handled  instrument  with  large  fenes- 
trated  blades.  Generally  the  fenestrae  are  from  one-third  to  one- half 


MYOMECTOMY    FORCEPS,   SCISSORS    AND    KNIVES. 


489 


of    a 


the  size  of  those  in  ordinary  obstetrical  forceps.     In   the  absence 
special  pattern,  embryotomy  forceps  may  be  employed. 

Heywood  Smith's  Myomectomy  Forceps  are  of  the  scissors-handle  pat- 
tern, with  jaws  having  large  loop-shaped  fenestrse  of  slender  construction. 
By  referring  to  figure  1121,  it  will  be  seen  that  the  loops  are  curved  both 


Figure  1121.    Heywood  Smith's  Myomectomy  Forceps. 


on  the  flat  and  on  the  edge,  while  the  inner  margins  are  provided  with 
sharp  teeth  projecting  backward  toward  the  handle.  The  fenestrae  are 
about  3  inches  in  length  by  i#  in  breadth  at  their  widest  point,  and 
the  total  length  of  the  forceps  is  about  13  inches. 

Myomectomy  Scissors. 

Scissors  for  myomectomy  should  be  constructed  with  at  least  one  sharp 
point,  that  the  structure  of  the  tumor  may  be  penetrated  for  excision. 


Figure  1122.    Myomectomy  Scissors. 

Myomectomy  Scissors  do  not  differ  from  the  pattern  of  Sims,  excepting 
in  the  shape  of  the  points  above  mentioned.  Usually,  they  are  8^  or  9 
inches  in  length.  The  details  of  shape  are  shown  by  figure  1122. 

Myomectomy  Knives. 

While  knives  with  long  shanks  of  various  patterns  may  be  employed  for 
this  purpose,  those  with  sickle-shaped  blades  are  advised  by  many  authors. 


Figure  1123.    Kelly's  Improved  Pattern  Sickle-shaped  Hysterectomy  Knife.      « 

Kelly's  Sickle-shaped  Knife,  employed  in  extirpating  large  submucous 
myomata,  as  exhibited  in  figure  1123,  differs  but  little  from  a  pattern 
employed  by  Pratt  for  the  same  purpose.  It  consists  of  a  short  handle  and 
shank,  terminating  at  one  end  in  a  curved  knife  with  a  concave  cutting 
edge,  and  at  the  other  in  a  separator  that  may  be  used  in  shelling  out 
any  remaining  portions  of  the  tumor.  With  this  knife,  wedge-shaped  pieces 
may  be  removed  until  the  myoma  is  so  reduced  in  size  that  the  balance 
may  be  removed  en  masse. 

Morcellement  Forceps. 

These  consist  of  strongly-built  forceps,  having  either  sharp  cutting  or 
biting  jaws,  or  provided  with  teeth  for  holding  and  manipulating  parts  of 
the  mass  for  excision. 


490 


GYNECOLOGICAL    SURGERY. 


Schultze's  Morcellement  Forceps,  as  portrayed  by  figure  1124,  are 
similar  in  construction  to  ordinary  bone-gouging  forceps,  excepting  that 
they  are  longer  and  more  delicate.  The  jaws  are  slender  and  cup-shaped, 


Figure  1124.    Schultze's  Morcellement  Forceps. 


with  sharp  cutting  margins.  They  are  intended  for  biting  or  cutting  away 
pieces  or  fragments  from  a  tumor  mass.  The  cutting  surface  of  the  jaw  is 
about  i  inch  in  length  and  the  total  length,  of  the  forceps  is  about  10  inches. 


Figure  1125.    Pean's  Morcellement  Forceps. 

Pean's  Morcellement  Forceps  are  strongly  built  and  provided  with  sharp, 
strong  teeth  set  in  the  inner  surface  of  each  jaw,  as  shown  by  figure  1125, 
thus  furnishing  an  unyielding  grasp. 

They  can  be  used  to  advantage  in  cases  where  dilatation  has  proceeded  to 
an  extent  that  will  admit  of  their  introduction.  With  them  a  portion  of 
the  tumor  may  be  grasped,  turned  downward  and  the  included  fragment 
separated  with  curved  scissors.  One  point  of  the  latter  should  be  sharp, 
that  it  may  easily  penetrate  the  tumor  mass,  while  the  other  should  be 
well-rounded  that  it  may  pass  between  the  tumor  and  the  uterine  wall. 

Spoon  Saw. 

This  may  be  employed  in  either  excision  or  enucleation.  .  In  its  con- 
struction it  embraces  the  principles  of  the  curette,  dissector  and  saw  blade. 
It  is  used  to  separate  or  "shell"  out  a  tumor  from  its  bed. 


Figure  1126.    Thomas'  Spoon  Saw. 

Thomas'  Spoon  Saw  consists  of  a  large  steel  spoon  curette,  the  edges  or 
margins  of  which  are  provided  with  a  dull  saw-toothed  edge.  When 
employed  either  for  dissecting  out  a  sessile  mass  or  for  severing  a  pedicle, 
the  back  or  rounded  portion  of  the  instrument  should  be  pressed  close 
against  the  inner  uterine  wall,  in  order  to  prevent  injury  to  its  tissues. 
With  a  rotary  or  sawing  motion  it  may  be  used  effectively.  As  manu- 
factured by  most  instrument  makers,  it  is  so  sharp  that,  even  with  care, 
the  uterine  wall  is  frequently  lacerated  and  occasionally  perforated.  As 


HYSTERECTOMY    AND    HYSTEROTOM Y.  491 

exhibited  by  figure  1126,  it  is  usually  about  y%  of  an  inch  broad,  with  a  bowl 
about  ify  inches  in  length,  the  whole  instrument  having  a  total  length  of 
ii  inches. 

Myoma  Enucleator. 

Some  form  of  instrument  is  necessary  for  peeling  or  separating  out  a 
tumor  mass.  While  many  operators  employ  the  handle  of  a  scalpel, 
periosteal  elevator,  blunt  dissector,  or  other  instrument  of  similar  form, 
an  especially  constructed  pattern  is  preferable.  They  should  be  designed 
with  blunt  edges  and  points. 


Figure  1137.    Frank's  Myoma  Enucleator. 

Frank's  Myoma  Enucleator,  as  will  be  seen  by  referring  to  figure  1127, 
has  a  strong  handle  and  shank,  terminating  in  a  short,  blunt  trowel-shaped 
blade,  slightly  curved  on  the  flat.  Owing  to  the  elasticity  of  the  uterine 
wall,  it  is  not  necessary  that  these  instruments  be  constructed  with  different 
curves,  as  the  outer  tissues  will  yield  to  the  force  of  the  instrument.  It 
may  be  used  for  peeling  out  or  separating  a  tumor  to  far  better  advantage 
than  the  improvised  handle  of  some  other  instrument. 

Hysterectomy  and  Hysterotomy. 

As  the  list  of  instruments  required  in  these  operations  is  determined 
not  by  the  character,  but  by  the  route  selected,  we  will  divide  the 
necessary  appliances  into  two  classes,  those  for  vaginal  and  those  for  abdom- 
inal operations. 

Vaginal  Hysterectomy  and  Hysterotomy. 

Either  of  these  operations  will  require  the  minor  operating  list  de- 
scribed on  pages  270  to  275,  together  with  nearly  all  the  following: 
Leg  holders,  for  securing  patient,  figures  194  to  197; 
Sims'  speculum,  for  exposing  uterus,  figure  991 ; 
Vaginal  depressor,  for  increasing  size  of  operating  field,  figure  1007; 
Long-handled  scissors,  for  excising  appendages,  etc.,  figure  928; 
Pedicle  ligature  carrier,  figure  1109; 

Volsellum  forceps,  for  manipulation  of  uterus,  figure  1025 ; 
Utero-tractor  or  tenaculum  forceps,  for  manipulation  of  uterus; 
Clamp  forceps,  for  controlling  ligamentous  hemorrhage; 
Retention  catheter,  to  prevent  contamination  of  packing; 
Soft  rubber  rectal  tube,  as  guide  in  rectum ; 
Knife,  for  excision  of  uterus ; 

Large  conical  vaginal  dilator,  for  dilatation  of  narrow  vaginal  outlet; 
Blunt  hook,  used  for  catching  and  drawing  down  ligatures. 

TJtero-Tractor. 

The  vaginal  operations  require  an  instrument  that  will  enable  the  surgeon 
to  obtain  a  firm  grasp  and  good  control  of  the  uterine  body.  Most  operators 
employ  a  double  tenaculum  forceps,  as  shown  by  figure  1024,  or  a  strong 
volsellum  forceps,  such  as  is  shown  by  figure  1026.  A  special  instrument 


492 


GYNECOLOGICAL   SURGERY. 


used  for  this   purpose   and   called   by  its  inventor  a  utero-tractor  is,  we 
believe,  worthy  of  mention  here. 

Bernays'  Utero-Tractor  is  an  intra-uterine  diverging  volsellum  forceps, 
about  10  inches  in  length,  strongly  built  and  terminating  in  blades  that 
are  curved  outward  on  the  edge  in  opposite  directions,  the  outer  margins 
being  provided  with  four  strongly-built  hooks.  A  spring  maintains  the 
handles  in  an  open  position,  thus  giving  to  the  blades  the  appearance  of  a 


Figure  1128.    Bernays'  Utero-Tractor. 


slightly-curved  ar  about  2  y?  inches  in  length.  In  this  form  it  is  easy  of 
introduction.  After  being  passed  through  the  cervix,  the  blades  are  sepa- 
rated by  closing  the  handles,  each  securing  a  firm  inner  grasp  along  the 
entire  length  of  the  cervix.  As  shown  by  figure  1128,  the  handles  are 
retained  in  position  with  a  suitable  ratchet  catch. 

Hysterectomy  Clamp  Forceps. 

Hysterectomy  clamp  forceps  are  usually  required  for  compressing  the 
ligaments,  in  order  to  prevent  hemorrhage  during  and  following  the  oper- 
ation. They  should  be  constructed  with  long  jaws  or  contact  surfaces  that 
they  may  be  used  to  grasp  extensive  breadths  of  vascular  tissues.  From 
four  to  eight  forceps  of  various  sizes  and  shapes,  should  be  provided,  the 
number  varying  with  the  size  of  the  tumor. 


Figure  1129.    Jacobs'  Hysterectomy  Clamp  Forceps. 


Jacobs'  Hysterectomy  Clamp  Forceps  consist  of  strongly- built  instruments 
of  the  compression  forceps  type.  They  differ  from  the  latter,  in  being 
heavier  and  provided  with  a  larger  number  of,  and  more  secure,  catches, 
the  latter  located  between  the  handle  loops.  As  illustrated  by  figure  1129, 
they  are  constructed  in  three  lengths,  6^,  7  and  7^  inches. 

Lewis'  Hysterectomy  Forceps,  as  exhibited  by  figures  1130  and  1131, 
consist  of  forceps  of  heavy  weight,  about  12  inches  in  length  and  with 
a  grasping  surface  5  inches  in  extent.  They  are  of  extra  heavy  construc- 
tion and  are  capable  of  exerting  great  pressure.  The  catches  are  so  con- 
structed as  to  insure  perfect  safety,  as  it  is  frequently  necessary  that  the 
instruments  shall  remain  in  position  for  from  one  to  three  days. 


HYSTERECTOMY    CLAMP    FORCEPS. 


493 


Newman's-Thumin's  Clamp,  as  represented  by  figure  1132,  consists  of  a 
powerful  steel  clamp  operated  by  screw  power.  It  is  employed  for  the 
compression  of  soft  tissues,  such  as  the  broad  ligament,  pedicles,  tumors, 


Figure  1130.    Lewis'  Angular  Hysterectomy  Forceps. 


Figure  1131.    Lewis'  Curved  Hysterectomy  Forceps. 


growths,  etc.  It  is  claimed  that  this  instrument  not  only  produces  com- 
plete hemostasis,  but  that  the  compressed  tissue  recovers  its  vitality,  and 
that  all  dangers  arising  from  sloughing  or  protruding  ends  of  stumps  are 
avoided.  Not  only  this,  but  the  subsequent  granulating  surface  is  mini- 


Figure  1132.    Newman's-Thumin's  Clamp. 

mized  and  the  dangers  of  adhesion  avoided.  The  instrument  may  be  suc- 
cessfully used  instead  of  a  ligature  in  the  removal  of  pedunculated  growths, 
and  in  clamping  the  broad  ligament  in  cases  of  hysterectomy.  In  the 
latter  operation  the  use  of  a  retention  clamp  and  of  ligatures  is  avoided, 


494 


GYNECOLOGICAL    SURGERY. 


and  retention  sutures  need  not  be  applied.  As  but  two  and  one-half 
minutes  are  necessary  for  its  proper  application,  the  instrument  possesses 
many  advantages. 

Hysterectomy  Knives. 

These  may  have  cutting  edges  or  be  used  with  the  galvano-or  thermo- 
cautery.  When  of  the  cutting  variety,  the  blades  are  usually  curved  on 
the  flat. 


Figure  1133.    Kelly's  Hysterectomy  Knife. 

Kelly's  Hysterectomy  Knife,  as  delineated  in  figure  1133,  consists  of  a 
strong  handle  and  shank  terminating  in  a  short  spear-pointed  blade, 
slightly  curved  on  the  flat.  The  blade  presents  two  lateral  cutting  edges, 
each  with  convex  margins.  The  pattern  is  admirably  adapted  for  amputa- 
tion and  enucleation  of  the  uterus,  for  which  purpose  it  was  especially 
constructed. 

Cautery  Knives  consist  of  slender  thermo-cautery  points  employed  in 
gynecological  surgery  for  severing  the  uterine  appendages,  the  pedicles 
of  tumors,  etc.  Like  other  forms  of  cautery  points,  they  are  hollow,  and 
are  manufactured  of  platinum. 


Figure  1134.    Straight  and  Curved  Thermo-Cautery  Knives. 

The  Straight  and  Curved  Cautery  Knives,  exhibited  in  figure  1134,  do 
not  differ  from  those  described  in  connection  with  figure  399,  excepting 
that  they  are  longer  and  usually  more  slender.  When  heated  to  a  bright 
red  color,  they  sever  tissues  quickly,  thoroughly,  and  with  less  hemorrhage 
than  the  ordinary  knife. 

Rectal  Tube  and  Self-retaining  Catheters. 

Some  operators  advise  that,  during  this  operation,  a  soft  rubber  tube  be 
passed  into  the  rectum,  in  order  that  the  canal  may,  at  all  times,  be  located 
and  distinguished  from  other  viscera. 


Figure  1136.    Skene's-Goodman's  Self-retaining 
Catheter. 


Figure  1135.     Soft  Rubber  Rectal  Tube. 


Figure  1137.     Kelly's  Vaginal  Dilator. 


RECTAL    TUBES VAGINAL    DILATORS.  495 

Soft  Rubber  Rectal  Tubes,  as  represented  by  figure  1135,  are  usually 
from  9  to  1 1  millimeters  in  diameter  and  about  30  inches  in  length. 

Self-retaining  Catheters.  These  are  provided  with  bulbs  or  other 
similar  devices  designed  to  hold  a  catheter  in  situ  until  released  by  force. 
They  may  be  either  rigid  or  flexible.  They  are  employed  to  prevent  voided 
urine  from  saturating  the  gauze  covering  of  the  clamp  forceps. 

Skene's-Goodman's  Self-retaining  Catheter,  as  represented  by  figure  1136, 
is  a  short,  slightly-curved  stem,  terminating  in  an  acorn-shaped  bulb 
provided  with  a  large  number  of  openings.  The  enlargement  of  the 
cerminal  portion  renders  this  instrument  self-retaining.  A  flange  is 
constructed  near  its  proximal  end  to  prevent  its  passing  wholly  within 
the  bladder.  A  suitable  tip  furnishes  means  for  the  attachment  of  a 
rubber  tube. 


Figure  1138.    Soft  Rubber  Self-retaining  Catheter. 

The  Soft  Rubber  Self-retaining  Catheter,  as  represented  by  figure 
1138,  consists  of  a  piece  of  rubber  tubing,  usually  about  No.  10,  American 
scale,  terminating  in  a  soft,  hollow,  flattened  bulb.  An  opening  through 
this  bulb  connects  with  the  lumen  of  the  tube.  The  bulb  is  of  thin  mate- 
rial, that  it  may  be  easily  compressed  within  a  metallic  tube  or  cylindrical 
urethral  speculum  and  thus  passed  into  the  bladder.  Upon  being  released 
the  bulb  will  expand  and  form  a  self-retaining  instrument.  If  a  speculum 
of  proper  form  is  not  at  hand  the  compressed  bulb  may  be  seized  in  the 
jaws  of  a  dressing  forceps  and  passed  through  the  urethra  into  the  bladder. 

Vaginal  Dilators. 

These  are  employed  in  certain  cases  to  enlarge  a  narrow  vaginal  outlet. 
They  may  be  conical,  or  may  have  blades  similar  to  vaginal  specula. 

Kelly's  Vaginal  Dilator,  as  represented  in  figure  1137,  consists  of  a 
hollow  cone,  to  the  base  of  which  a  firm  handle  is  attached.  The  cone  is 
about  4^  inches  in  extreme  length,  about  ^  of  an  inch  in  diameter  at  the 
point,  and  2  inches  in  diameter  at  its  base.  Graduations  at  intervals  of  iy2 
millimeters  are  stamped  with  the  number  of  millimeters  at  that  point. 

Blunt  Hooks. 

These  are  employed,  not  only  as  a  means  of  counter-pressure  when 
penetrating  deep  tissues  with  a  needle,  but  for  the  manipulation  of  sutures, 
ligatures,  etc. 


Figure  1139.    Plain  Blunt  Hook. 


The  Plain  Blunt  Hook,  exhibited  in  figure  1139,  consists  of  a  firm 
shank  provided  with  a  handle,  the  distal  end  of  the  former  being  curved 
in  hook  shape. 


496 


GYNECOLOGICAL    SURGERY. 


Abdominal  Hysterectomy  and  Hysterotomy. 

Either  of  these  operations,  whether  for  uterine  amputation  or  complete 
extirpation,  will  require  nearly,  if  not  all  of  the  following : 
Minor  operating  list,  pages  270  to  275. 
Laparotomy  list,  page  414. 

Traction  forceps,  for  manipulation  of  tumor,  figure  1094. 
Screw,  for  manipulation  of  uterus. 
Uterine  tourniquet,  for  constriction  of  uterus,  or, 

Elastic  ligature,  for  constricting  or  severing  the  uterus,  see  page  485. 
Serre-noeud,  for  constricting  or  severing  the  uterus. 
Pliers,  for  cutting  the  constricting  wires. 
Hysterectomy  needles,  where  stump  is  treated  extra-peritoneally. 

Tumor  Screws. 

These  are  employed  for  raising  and  manipulating  dense  tumors.     Two 
or  more  are  sometimes  required  for  dislodging  large  impacted  masses. 


Figure  1140.    Tait  s  Myoma  Screw. 


Tait's  Myoma  Screw  was  designed  as  an  improvement  on  the  common 
corkscrew  formerly  employed.  As  it  appears  in  figure  1 1 40,  it  is  of  strong 
metal  construction,  with  sharp  point,  and  about  5  ^  inches  in  length. 

Uterine  Tourniquets. 

These  are  employed  for  temporary  circular  constriction  of  the  pedicle 
during  the  operation  and  preceding  the  application  of  the  serre-noeud. 
They  are  usually  removed  as  soon  as  the  wire  of  the  latter  is  tightened. 


'.  Figure  1141.    Pozzi's  Uterine  Tourniquet,  for  Use  with  Elastic  Ligature. 

Pozzi's  Uterine  Tourniquet,  as  illustrated  by  figure  1141,  consists  of  a 
shank  terminating  in  a  fenestrated  head  through  which  an  elastic  ligature 
may  be  caused  to  pass.  A  suitable  dog  is  attached  to  the  shank,  by  means 
of  which,  after  being  tightened,  the  rubber  ligature  may  be  firmly  held  in 
place.  A  detachable  handle  is  also  provided,  thus  enabling  the  surgeon 
to  remove  the  handle  of  the  instrument  in  cases  where  it  is  necessary  to 
permit  the  ligature  to  remain  in  action  for  a  considerable  length  of  time. 
With  this  apparatus,  automatic  tension  may  be  indefinitely  maintained. 


SERRE-NOEUD CUTTING    PLIERS. 


The  Serre-Noeud. 

This  instrument  may  be  employed  for  constricting  the  uterus  at  or 
near  the  os  internum  with  a  strong  steel  wire.  It  serves  as  a  permanent 
clamp  during  the  separation  of  the  pedicle  end  by  sloughing.  The  wire 
loop  is  usually  passed  around  the  tumor,  ovaries,  tubes,  and  as  much  of 
the  broad  ligament  as  can  be  drawn  above  the  wire,  after  which  it  is  drawn 
tight  enough  to  prevent  hemorrhage.  Care  should  be  exercised  to  exclude 
bowels,  bladder-walls,  etc.  In  case  a  wire  should  slip,  break  or  need  relo- 
cating, a  duplicate  should  always  be  in  readiness. 


Figure  1143. 


Koeberle's  Serre-Noeud  is  a  strongly-built,  diminutive  wire  ecraseur. 
Including  the  handle,  the  instrument  need  not  be  more  than  6  inches  in 
length.  As  it  appears  in  figure  1142,  it  consists  of  a  slotted  shaft,  in  the 
lumen  of  which,  and  attached  to  the  terminal  portion  of  the  instrument,  a 
double-threaded  screw  is  caused  to  revolve  by  means  of  a  flattened  handle. 

Traveling  back  and  forth  upon  this  screw  is  a  nut  with  projecting 
shank,  to  which  a  wire  loop  may  be  attached.  The  distal  end  of  the  instru- 
ment terminates  in  a  neck  and  head,  the  latter  flattened  and  containing  a 
slot  located  in  a  line  with  the  traveling  nut  previously  referred  to.  By 
encircling  the  pedicle  with  the  wire,  passing  the  ends  through  the  slot, 
securing  the  same  to  the  traveling  nut  and  turning  the  screw,  the  wire 
loop  may  be  gradually  drawn  through  the  slot  and  the  engaged  tissues 
slowly  but  surely  severed. 

Aluminum  wire,  owing  to  its  pliability  and  tensile  strength,  is  strongly 
recommended  by  many  authors,  a  steel  wire  known  as  "Delta  wire"  being 
also  used.  Piano  wire,  though  sometimes  employed,  is  too  stiff,  frequently 
cutting  rather  than  constricting. 

Cutting  Pliers. 

These  are  required  for  severing  the  unemployed  ends  of  wire  after 
the  loop  has  been  secured  by  twisting  the  strands  on  the  traveling  nut. 


u re  1143.    Koeberle's  Cutting  Pliers. 


Koeberle's  Cutting  Pliers  consist  of  a  strongly-built  forceps,  about  4^' 
inches  in  length,  with  jaws  designed  for  twisting,  holding  and  cutting  steel 
wire.  As  is  manifest  in  figure  1143,  the  main  portion  of  the  jaws  is 
devoted  to  holding  and  cutting  the  wire.  Upon  one  side  a  face  armed  with 
saw  teeth  is  provided  to  prevent  the  wire  from  slipping  away  from  the 
grasp  of  the  instrument.  The  opposite  side  is  flat  and  presents  a  somewhat 

32 


498  GYNECOLOGICAL    SURGERY. 

sharp  edge,  by  means  of  which  the  wire  is  forced  between  the  saw-teeth  edges 
and  there  severed.  The  jaws  of  this  instrument  terminate  in  a  flattened 
contact  surface,  used  for  grasping  the  two  wires  simultaneously  and  twisting 
them  together. 

Hysterectomy  Needles. 

Special  needles  or  pins,  sometimes  called  skewers,  are  required  in  oper- 
ations where  the  stump  is  dressed  and  secured  in  an  extra-peritoneal  posi- 
tion. Usually  two  are  employed,  with  which  the  stump  is  transfixed  in 
opposite  directions  just  above  the  wire,  where  they  serve  to  hold  the 
stump  within  the  wound,  preventing  it  from  slipping  backwards  into  the 
peritoneal  cavity.  That  they  may  not  become  embedded  in  the  skin  upon 
retraction  of  the  stump,  the  ends  are  usually  supplied  with  caps  or  the 
skin  protected  by  small  roller  bandages  placed  underneath. 


Figure  1144.    Koeberl6's  Hysterectomy  Pin. 

Koeberle's  Hysterectomy  Pins,  as  illustrated  by  figure  1144,  consist  of 
stout  steel  pins  attached  to  a  small,  flat,  oval  handle.  The  point  is  guarded 
by  a  removable  disc  of  the  same  size  and  shape  as  the  handle.  This  disc 
is  provided  with  a  small  tube  attached  to  one  side,  by  means  of  which  it 
serves  as  a  cap  for  the  end  of  the  needle.  Usually  they  are  about  4  inches 
in  length.  Two  are  required  for  each  operation. 


Figure  1145.     Peck's  Hysterectomy  Pin. 

Peck's  Hysterectomy  Pin,  as  shown  by  figure  1145,  consists  of  a  steel 
pin  about  5  inches  in  length.  In  shape  it  does  not  differ  materially  from 
an  ordinary  pin.  When  in  use  the  skin  is  protected  by  layers  of  cloth  or 
small  roller  bandages. 

PERINEORRHAPHY. 

The  instruments  required  for  this  operation  are : 

Minor  operating  lists,  on  pages  270  to  275. 

Sims'  speculum,  for  retracting  anterior  vaginal  wall,  figure  991, 

Tissue  forceps,  for  flap  dissections,  figure  605, 

Tenacula,  for  manipulation  of  flaps,  figure  950, 

Scissors  with  sharp  points ;  or, 

Knives  for  forming  flaps,  figures  550  to  565, 

Needles  for  uniting  flaps ; 

Sutures,  catgut,  silkworm  gut  or  silver  wire,  page  317. 
If  Silver  Wire  be  Used, 

Wire-cutting  scissors,  figure  788, 

Wire  adjuster, 

Wire  twister,  figure  784. 

Scissors. 
Scissors  for  this  operation  should  have  thin  blades  and  sharp  points. 


PERINEORRHAPHY. 


499 


Jenks'    Perineorrhaphy  Scissors,    as    shown    by  figure    1146,    are    con- 
structed with  thin  blades,  slightly  curved  on  the  flat.     They  are  provided 


Figure  1146.    Jenks'  Perineorrhaphy  Scissors. 


with  fine  points  and  sharp  lateral  margins,  particularly  adapted  for  fine 
dissections. 

Perineum  Needles. 

Needles  for  use  in  operations  on  the  perineum  are  usually  constructed 
with  large  curves,  solid  handles,  and  with  the  eye  in  the  point. 


Figure  1147.    Plain  Perineum  Needle. 

The  Plain  Perineum  Needle,  as  set  forth  by  figure  1147,  is  constructed 
from  a  single  piece  of  steel  and  is  curved  on  the  flat.  It  is  provided  with 
a  large  eye  in  the  point  thus  enabling  it  to  be  quickly  threaded. 


Figure  1148.    Robinson's  Perineum  Needle. 


Robinson's  Perineum  Needle,  as  traced  in  figure  1148,  differs  from  the 
plain  pattern  last  described,  in  being  constructed  with  a  long,  sweeping 
curve,  which  its  inventor  claims  is  better  adapted  for  perineal  use.  It  is 
constructed  with  a  hollow  handle,  thus  forming  an  instrument  that  is  light 
without  impairing  its  utility. 


Figure  1149.    Skene's  Perineum  Needle. 

Skene's  Perineum  Needle,  as  represented  by  figure  1149,  consists  of  a 
stout  shank  and  handle,  the  former  terminating  in  a  needle  provided  with 
an  open  eye.  Unlike  the  two  patterns  previously  described,  this  needle  is 
passed  through  the  flaps  to  be  united  before  being  threaded,  the  suture 
being  threaded  in  the  eye  of  the  needle  and  drawn  through  the  stitch  holes 
by  the  withdrawal  of  the  needle.  They  may  be  procured  either  straight 
or  curved. 


Figure  115ft     Peaslee's  Perineum  Needles. 


Peaslee's  Perineum  Needles,  as    sketched   in  figure  1150,  include  a  set 
of  three;  one  straight,  one  slightly  curved,  and  one  medium  curved.     The 


500 


GYNECOLOGICAL    SURGERY. 


needles  are  attached  to  a  handle  by  means  of  a  screw  joint.  A  late 
design  shows  a  construction  in  which  a  hollow  octagonal  handle  is  employed, 
the  three  needles  when  not  in  use  being  contained  within  the  handle,  the 
proximal  end  of  which  is  closed  with  a  screw  cap.  The  surgeon  who  has 
this  instrument  is  supplied  with  three  needles  of  different  shapes. 


Figure  1151.    Riverdin's  Closing-eye  Needle. 

Riverdin's  Closing-eye  Needle,  fully  described  by  figure  1151,  is  largely 
employed  in  this  operation.  The  pattern  here  shown  is  provided  with  a 
long,  sweeping  curve  that  particularly  fits  it  for  this  purpose.  When  of 
all-metal  construction  and  with  a  hollow  handle,  it  forms  a  serviceable 
instrument. 

Sims'  Perineum  Needle,  as  shown  by  figure  1152,  consists  of  a  round 
shaft  and  triangular  point,  the  latter  slightly  curved.  The  inner  face  rep- 
resents the  long  face  of  a  triangle,  the  outer  one  being  an  obtuse  angle. 
This  needle  penetrates  easily,  and,  though  the  use  of  a  needle  holder,  is 
necessitated,  is  preferred  by  some  operators.  It  is  usually  about  2  inches 
in  length 

Goodell's  Perineum  Needles,  as  represented  in  figure  1153,  are  double 
curved  with  spear  points.  They  are  usually  to  be  had  in  about  three  sizes, 
their  full  length  being  shown  in  the  illustration.  They  may  be  used  with 
or  without  a  needle  holder. 


TRURXGREENESCn 


Figure  1152.    Sims'  Perineum  Needle. 


Figure  1153.    Goodell's  Perineum  Needle. 


Figure  1154.    Wilson's  Perineum  Needle. 


Wilson's  Perineum  Needle,  as  exhibited  in  figure  1154,  consists  of  a 
short,  stout  handle  about  i  y?  inches  in  length,  terminating  in  a  full  curved 
needle  of  about  3  inches  in  length.  This  combination  forms  a  strong 
pattern  and  furnishes  an  instrument  easily  controlled  by  the  operator. 

TRACHELORRHAPHY  AND  TRACHELOPLASTY. 

This  operation  will  require  the  following  list  of  instruments: 

Minor  operating  list,  on  pages  270  to  275. 

Leg  holder,  for  securing  patient  in  proper  position,  figures  194  to  197. 

Scarificator,   sometimes  used  to  deplete  cervix  previous  to  operation. 

Sims'  speculum,  large  size,    for  exposing  field  of  operation,  figure  991. 


TRACHKLORRHAPHY.  501 

Lateral  retractors,  for  enlarging  operating  field,  figure  995. 

Tenacula,  for  manipulation  of  flaps  and  dissections,  figure  950. 

Tenaculum  forceps,  for  manipulation  of  uterus. 

Volsellum  forceps,    small,  for  use  where  uterus  is  firmly  in  position, 
figure  1026. 

Curette,  sometimes  required  previous  to  operating,  figure  1078. 

Scissors,  strong,  for  removal  of  cicatricial  tissue. 

Knives,  long-handled,  sometimes  used  instead  of  scissors. 

Dressing  forceps,  for  making  applications,  packing,  etc.,  figure  1028. 

Uterine  sound,  for  determining  condition  of  cervical  canal,   figure  1019. 

Male   urethral    sound,    sometimes    preferred    to    the    uterine    sound, 
figure  1359. 

Dilator,  for  dilatation  of  internal  os,  figure  1036. 

Sponges,  small, figure  687. 

Sponge  holders,  figure  935. 

Sutures,  catgut,  silkworm  gut,  or  silver  wire,  page  317. 

Ligatures  for  leaders,  page  322. 

Needles,  large,  curved,  for  inserting  leaders. 

Needles,  for  uniting  flaps,  figure  740. 

Counter-pressure  instrument,  to  assist  passing  of  needle. 

Needle  holder,  strong,  figiires  756  to  768. 

Shot  compressor  (if  shot  be  used),  figure  781. 

Glass  cervical  stem. 

Tampons,  for  packing  around  cervix. 
If  wire  be  used: 

Wire-cutting  scissors,  figure  788. 

Wire-twisting  forceps,  figure  782. 

Wire  adjuster,  figure  1175. 

Scarlflcators. 

Kelly  advises  that  the  cervix  be  depleted  by  repeatedly  puncturing  all 
dilated  follicles  for  some  time  previous  to  the  operation. 


Figure  1155.     Kelly's  Angular  Scarificator. 

Kelly's  Angular  Scarificator,  as  indicated  by  figure  1155,  and  called  by 
its  inventor  a  "knife-blade  tenaculum, "  consists  of  a  tenaculum-like  handle, 
terminating  in  a  small  triangular  blade  not  unlike  the  well-known  angular 
keratome  of  Jaeger  used  in  operations  on  the  eye.  The  blade  should  not 
exceed  ^  of  an  inch  in  length. 

Scissors. 

Scissors  for  denuding  the  lips  of  a  lacerated  cervix  should  possess  strong 
short  blades.  As  the  success  of  an  operation  depends  on  securing  complete 
denudation,  care  should  be  exercised  in  selecting  scissors  that  present  good 
cutting  edges  throughout  the  entire  length  of  the  blade. 

Emmet's  Scissors  are  available  for  trachelorrhaphy,  closure  of  fistulas 
and  plastic  operations.  Being  bent  on  the  edge,  as  well  as  curved  on  the 
flat,  they  enable  the  operator  to  form  lines  of  incision  in  almost  any  direc- 
tion, assuming  any  angle  or  degree  of  curvature.  The  patterns  here  shown 

LLUlilE   Uj 

1=1-1  Y  ^! 


502 


GYNECOLOGICAL    SURGERY. 


are  both  curved  toward  the  right  and  are  for  use  with  the  right  hand. 
Similar  ones  curved  to  the  left,  also  for  the  right  hand,  may  be  purchased 


Figure  1156.    Emmet's  Scissors  Slightly  Curved  to  Right. 


Figure  1157.    Emmet's  Scissors  Sharply  Curved  to  Right. 

from  instrument  dealers.     They  can  seldom,  however,  be  used  to  as  good 
advantage  as  those  shown  in  figures  1156  and  1157. 

The  sharply-curved  scissors  are  well  adapted  to  cervix  and  fistula  opera- 
tions, and  the  slightly-curved  to  cervical,  perineal  and  general  intra- vaginal 
and  intra-abdominal  denudations. 


Figure  1158.    Sims'  Scissors  Curved  on  the  Flat  with  One  Point  Sharp. 

Sims*  Scissors,  when  curved  on  the  flat  and  of  good  quality,  may  be 
made  serviceable  for  this  operation.  Those  with  one  point  sharp,  as 
appears  in  figure  1158,  and  8  to  8^  inches  in  length,  are  usually  preferred. 


FiRiire  1159.     Skene's  Hawkbill  Scissors. 

Skene's  Hawkbill  Scissors,  as  manifest  in  figure  1159,  are  designed  for 
removing  the  cicatricial  tisue  forming  the  angle  of  a  lacerated  cervix  by 
a  single  bite  or  incision.  Though  called  by  their  author  a  scissors,  they 
consist  of  a  punch  with  sharp  cutting  edges  fitting  accurately  into  a  fenes- 
trated  blade,  so  that  by  pressure  upon  the  handles  any  tissues  included  in 
the  bite  of  the  instrument  may  be  punched  out. 


TRACHELORRHAPHY. 


503 


Hanks'  Trachelorrhaphy  Scissors  possess  blades  that  are  curved  both  on 
the  edge  and  on  the  flat,  much  after  the  pattern  of  the  lesser  curved  scis- 
sors of  Emmet,  shown  by  figure  1156.  They  differ  materially,  however, 
in  that  the  blade  tips,  on  their  inner  surfaces,  terminate  in  hook-like  pro- 


Figure  1160.    Hanks'  Trachelorrhaphy  Scissors. 


jections,  the  two  so  shaped  that  when  embedded  in  the  cervical  tissues  by 
the  closing  of  the  blades,  the  parts  will  be  firmly  held  until  severed.  By 
grasping  the  entire  mass  to  be  incised  a  perfectly  denuded  field  may  be  ob- 
tained with  a  single  cut.  They  are  well  illustrated  by  figure  1160. 


Knives. 


Knives  for  uterine  work  differ  from  those  employed  in  ordinary  opera- 
tions, principally  in  the  length  of  shank,  which  in  most  cases  increases  the 
length  of  the  instrument  to  about  8^' inches. 


Figure  1161.    Uterine  Scalpel. 


Figure  1162.    Uterine  Knife,  Angular-Bent  to  Right. 


Figure  1163.    Uterine  Knife,  Angular-Bent  to  Left. 


Figure  1164.    Uterine  Knife,  Curved  on  the  Flat,  with  Double  Edge. 

Uterine  Scalpel,    as  shown  by  figure    1161,  is   of  the  ordinary  scalpel 
pattern. 

Uterine  Knives,  Angular-Bent  to  right  and  left,  as  exhibited  by  figures 


Figure  1165.    Newman's  Trachelorrhaphy  Knife. 


1162  and  1163,  are  really  bistouries,  bent  in  the  shank  in  the  direction  of 
the  flat  of  the  blade.     With  the  pair,  the  operator  may  cut  in  any  direction, 


uU4  GYNECOLOGICAL    SURGERY. 

Uterine  Knife  Curved  on  the  Flat  with  double  edge,  as  represented  by 
figure  1164,  has  only  a  slight  curve. 

Newman's  Trachelorrhaphy  Knife,  as  displayed  by  figure  1165,  consists 
of  a  blade  with  cutting  edge,  straight,  but  at  nearly  a  right  angle  with  the 
handle.  Its  deviser  transfixes  the  cervix  at  the  inner  angle  of  the  "V"  and 
cutting  outward  forms  flaps  with  entire  fresh  surfaces  with  two  incisions. 

Cervical  Needles. 

Needles  for  trachelorrhaphy  and  similar  operations  should  be  strong 
and  have  points  adapted  for  the  penetration  of  dense  cicatricial  tissues. 
Nearly  all  will  require  the  use  of  a  needle  holder. 


TRUAX  GREENE -CO. 


TRUAX"  GREENE- CO. 

« _^_  ^=V 

Figure  1166.    Sims'  Trocar-  Figure  1167.    Sims'  Lance-  Figure  1168.    Emmet's  Lance- 

Point  Needles.  Point  Needles.  Point  Needles. 

Sims'  Trocar-Point  Needles,  as  shown  in  figure  1166,  are  short  and 
heavy,  with  round  shaft  and  long  trocar-shaped  points.  By  trocar-shape, 
is  meant  that  the  shape  of  the  needle  point  is  nearly,  if  not  quite,  that  of 
an  equilateral  triangle.  When  curved,  these  needles  present  a  flat  inner 
surface ;  that  is,  they  are  curved  on  the  flat  of  one  of  the  facets,  and  not  on 
the  edge.  They  are  either  straight  or  half-curved  and  of  the  full  sizes 
shown  in  the  illustration.  They  are  commonly  known  as  Sims'  fistula 
needles. 

Sims'  Lance-Point  Needles,  as  exhibited  in  figure  1167,  have  round 
shafts  and  points  which  closely  resemble  a  right-angled  triangle,  curved  on 
the  flat  of  the  long  facet.  The  curved  portion  or  point  of  these  needles  is, 
therefore,  wider  than  the  shaft.  They  are  usually  to  be  found  in  three 
sizes,  varying  from  i  to  i  yz  inches  in  length.  They  are  often  known  as 
Sims'  cervical  needles. 

Emmet's  Lance-Point  Needles,  as  illustrated  by  figure  1168,  differ  from 
the  lance-point  needles  of  Sims,  in  being  heavier  and  wider  at  their  cutting 
edge.  Usually  they  are  to  be  had  in  three  sizes,  varying  from  i  to  if6 
inches  in  length. 


Figure  1169.    Emmet's  Trocar-       Figure  1170.    Kelly's  Trache-    Figure  1171.    Murphy's  Trache- 
Point  Needles.  lorrhaphy  Needles.  lorrhaphy  Needles. 

Emmet's  Trocar-Point  Needles,  as  shown  in  figure  1169,  differ  from 
the  pattern  of  Sims  previously  described,  in  being  longer,  heavier  and 
having  shorter  points.  The  point  forms  an  equilateral  triangle  curved  on 
one  edge,  the  two  upper  faces  being  somewhat  longer  than  the  under  one. 


TRACHELORRHAPHY.  505 

They  may  be  purchased  straight,  half-curved  and  full- curved,  each  varying 
in  length  from  i  to  i5/8  inch. 

Kelly's  Trachelorrhaphy  Needle,  shown  full  size  in  figure  1 1 70,  is  short, 
with  a  straight  shank  and  curved  body,  the  point  continuing  in  the  same 
curve  as  the  main  portion. 

Murphy's  Trachelorrhaphy  Needles,  as  set  forth  in  figure  1171,  are  of 
short,  heavy  construction,  the  main  body  a  flattened  oval  in  form,  while 
the  needle  point  is  a  right-angled  triangle  curved  on  the  edge,  the  long 
face  of  the  triangle  being  on  the  outer  border.  The  needles  are  full 
curved,  each  representing  one-half  the  arc  of  a  circle,  and  the  sizes  are 
shown  in  the  illustration. 

Counter-Pressure  Instruments. 

These  are  employed  to  furnish  counter-retraction  to  offset  that  exerted 
by  the  exit  of  a  needle  through  sutured  tissues.  Their  use  facilitates  the 
passage  of  the  needle,  particularly  through  dense  and  indurated  masses. 


Figure  1172.    Sims'  Counter-Pressure  Hook. 

Sims'  Counter-Pressure  Hook,  as  displayed  by  figure  1172,  consists  of  a 
handle  and  shank  terminating  in  a  plain  small  blunt  hook,  the  entire 
instrument  being  about  8  inches  in  length.  It  should  be  constructed  of 
steel  or  other  firm  material,  that  it  may  furnish  the  necessary  pressure  to 
overcome  the  resistance  caused  by  the  pressure  of  the  needle. 


Figure  1173.    Wylie's  Counter-Pressure  Fork. 

Wylie's  Counter-Pressure  Fork,  as  indicated  by  figure  1173,  differs  from 
the  pattern  of  Sims',  in  that  the  shank  terminates  in  a  fork,  both  prongs 
of  which  may  be  utilized  to  exert  pressure,  one  upon  each  side  of  the 
needle  point. 


Figure  1174.     Skene's  Counter-Pressure  Ring. 

Skene's  Counter-Pressure  Ring,  as  set  forth  by  figure  1174,  consists  of 
a  solid  piece  of  steel  forming  a  handle  and  shank,  the  latter  terminating 
in  a  lightly  constructed  ring,  having  an  internal  diameter  of  about  %  of  an 
inch.  By  applying  this  ring  over  the  point  of  a  needle,  as  it  appears, 
firm  and  close  contact  with  the  surrounding  surfaces  may  be  obtained. 

"Wire  Shields  or  Adjusters. 

These  are  employed  for  holding  together  and  shouldering  the  two  ends 
of  the  silver  wire  forming  a  suture.  The  use  of  this  appliance  secures 
close  adaptation  of  the  approximating  parts  without  producing  unnecessary 
tension  on  the  tissues  by  the  drawing  of  the  suture  upon  the  margin  of  the 

stitch-hole. 


Figure  1175.    Sims'  Wire  Shield. 


Sims'  Wire  Shield,  as  appears  in  figure  1175,  consists  of  a  handle 
with  slender  shank,  terminating  in  a  broad  oblong  plate,  in  the  distal 
end  of  which  a  slot  is  provided  through  which  the  two  ends  of  the  wire 


506  GYNECOLOGICAL    SURGERY. 

suture  may  be  carried  or  drawn,  and  there  held  in  close  approximation  while 
being  twisted.  The  instrument  may  be  further  employed  for  shouldering 
purposes.  This  consists  in  forcing  or  pushing  outwards,  or  laterally,  upon 
a  wire  loop,  that  undue  pressure  may  not  be  exerted  upon  the  stitch-hole. 

Glass  Steins. 

These  are  required  in  cases  of  deep  laceration,  where  it  is  necessary  to 
remove  all  or  nearly  all  the  mucous  surface  from  one  or  both  lips  of  the  cer- 
vix. They  serve  to  maintain  the  patency  of  the  canal,  preventing  it  from 
being  closed  by  granulations. 


Figure  1176.    Glass  Cervical  Plug.  Figure  1177.    Cotton  Tampon. 

Glass  Cervical  Plugs,  as  manifest  by  figure  1176,  consist  of  a  glass  stem, 
about  7  millimeters  in  diameter  and  2  to  3  inches  in  length,  either  hollow 
or  solid.  The  original  patterns  were  manufactured  from  a  solid  rod  of 
glass,  but  latterly  they  have  been  made  from  tubing  and  provided  with  an 
opening  at  the  distal  end,  thus  allowing  secretions  to  pass  through  the  in- 
strument. 

Tampons. 

Tampons  for  packing  around  the  cervix,  following  operations,  may  be 
of  cotton,  gauze,  or  other  material.  Figure  1177  illustrates  a  convenient 
form  that  should  be  prepared,  sterilized  and  in  readiness  for  use. 

CLOSURE  OF  VAGINAL  FISTULA. 

Fistulae  connecting  with  the  vagina,  although  they  may  differ  in  loca- 
tion, are,  as  a  rule,  subject  to  operation  with  the  same  set  of  instruments, 
which  should  include  the  following: 

General  requirement  list,  see  pages  270  to  275. 

Leg  holder,  for  securing  patient  in  proper  position,  figures  194  to  197. 

Sims'  speculum,  large  size,  for  exposing  field  of  operation,   figure  991. 

Lateral  retractors,  for  enlarging  operating  field,  figure  995. 

Long  tissue  forceps,  for  holding  tissues  for  excision,  figure  948. 

Tenacula,  for  manipulation  of  flaps,  figure  950. 

Scissors,  for  denuding  edges  of  fistula,  figure  1122. 

Knives,  long  handled,  used  by  some  operators  instead  of  scissors, 
figure  1161. 

Compression  forceps,  in  cases  of  hemorrhage,  figure  938. 

Artery  needles,  should  ligation  of  a  vessel  become  necessary,  figure  1 109. 

Volsellum  forceps  for  manipulation  of  uterus,  figure  1025. 

Sponges,  figure  687. 

Sponge  holders,  figure  935. 


VAGINAL    FISTULA.  507 

Needles,  with  non- cutting  edges,  for  closure  of  fistula,  figure  955. 

Needle  holder,  figures  756  to  768. 

Counter-pressure  hook,  to  assist  in  passing  needle,  figure  1172. 

Ligatures,  for  vessels  requiring  ligation,  page  322. 

Sims'  vaginal  plugs,  for  retaining  patency  of  vagina. 

Catheters,  self- retaining,  to  prevent  soiling  of  drains,  figure  1138. 
If  Bozeman's  Method  be  Employed. 

Bozeman's  buttons,  figure  778. 

Silkworm  gut,  catgut  or  silver  wire,  page  317. 
If  the  Latter  be  Used. 

Shield  or  wire  adjuster,  figure  1175. 

Wire  twisting  forceps,  figure  782. 

Wire  cutting  scissors,  figure  778. 

Scissors. 

Scissors,  for  use  on  fistulae,  should  be  of    fine  quality  and  have  short 
blades  and  long  handles. 


Figure  1178.     Byford's  Fistula  Scissors. 


Byford's  Fistula   Scissors,  as  indicated  in  figure  1178,  are  constructed 
with  short  jaws,  both  points  rounded  and  with  long  handles. 

Vaginal  Plugs. 

These  consist  of  tubes  or  cylinders  closed  at  one  end  and  employed  to 
maintain  the  patency  of  the  vagina  following  operations  for  fistula. 


Figure  1179.    Sims'  Glass  Plug. 

Sims'  Glass  Plug,  as  pictured  in  figure  1179,  consists  ot  a  glass  cylin- 
drical cup,  the  distal  end  of  which  is  well  rounded.  Upon  one  side  and 
near  the  open  end  a  bowl  shaped  depression  is  formed  to  receive  the  ure- 
thra that  no  pressure  may  be  exerted  upon  that  organ. 

They  are  usually  worn  a  few  hours  daily,  their  removal  being  followed 
by  a  douche.  They  may  be  obtained  of  any  diameter  desired. 

HYSTERORRHAPHY. 

Suspension  of  the  uterus  may  require  the  following  list  of  instruments : 
Laparotomy  set,  page  415. 
Suspension  elevators. 


508  GYNECOLOGICAL    SURGERY. 

Suspension  Elevators. 

These  are  employed  to  raise  and  hold  the  uterus  in  position  during  its 
attachment  to  the  abdominal  wall.  Generally  they  consist  of  levers  bent 
to  almost  a  right  angle  with  the  shaft,  the  projecting  arm  being  of  sufficient 
length  to  engage  and  hold  the  uterus. 


Figure  1180.    Kelly's  Uterine  Elevator. 

Kelly's  Uterine  Elevator,  as  exhibited  in  figure  1180,  consists  of  a 
strong  shank  and  blade,  the  latter  bent  downward  at  an  angle  of  about  100°. 
The  blade  throughout  its  long  diameter  presents  a  concave  or  trough-like 
form,  its  outer  margin  being  also  concave  or  hollowed  out.  This  instrument 
is  used  as  a  lever  for  uterine  elevation  in  cases  of  suspension ;  the  length 
of  the  blade  is  sufficient  for  its  outer  border  to  hold  the  uterine  body  by  firm 
contact. 

AMPUTATION  OF  THE  CERVIX. 

The  instruments  required  for  this  operation  consist  of: 
General  requirement  list  on  pages  270  to  275. 

Leg  holder,  for  securing  patient  in  proper  position,  figures  194  to  197. 
Sims'  speculum,  for  exposing  field  of  operation,  figure  991. 
Retractors,  for  enlarging  operating  field,  figure  995. 
Scissors,  heavy,  figure  1122. 

Long-handled  knives,  for  incision  of  uterus,  figure  1161. 
Long  tissue  forceps,  for  making  dissections,  figure  948. 
Tenacula,  for  manipulation  of  flaps,  figure  950. 
Tenaculum  forceps,  figure  1021. 

Volsellum  forceps,  for  manipulation  of  uterus,  figure  1025. 
Uterine  dressing  or  packing  forceps,  figure  1028. 
Compression  forceps,  for  arresting  hemorrhage,  figure  938. 
Artery  needle,  for  passing  ligatures,  figure  1109. 
Needles,  for  suturing. 
Needle  holder  figures  756  to  758. 

Sutures,  catgut,  silkworm  gut,  silk  or  silver  wire,  page  317. 
If  the  Latter  be  Used,  the  following  will  also  be  required: 
Wire  cutting  scissors,  figure  788. 
Wire  twister,  figure  782. 
Wire  adjuster,  figure  1175. 

ALEXANDER'S  OPERATION. 

The  instruments  required  for  the  operation  of  Alexander  may  consist  of- — 
Minor  operating  list,  see  pages  270  to  275. 
Ligament  hook. 
Ligament  carrier. 


LOCAL    TREATMENT.  509 

Ligament  Hooks. 

These  consist  of  hook-shaped  instruments  that  may  be  either  blunt  or 
probe-pointed.  In  the  absence  of  a  special  pattern  an  aneurysm  needle, 
blunt  tenaculum  or  strabismus  hook  will  answer  the  purpose. 


Figure  1181.    Frank's  Round  Ligament  Hook. 

Frank's  Round  Ligament  Hook,  as  explained  in  figure  1181,  consists  of 
a  handle,  one  end  of  which  is  in  button-hook  form,  the  opposite  being  flat- 
tened and  sharpened  to  act  as  a  spud  or  tissue  separator.  It  is  employed  in 
performing  Frank's  or  Alexander's  operation.  After  pushing  back  the 
transversalis  fascia  from  Pou part's  ligament  with  the  spud  end  of  m  the  in- 
strument, the  hook  is  pushed  into  the  properitoneal  fat  and  the  ligament 
hooked  out.  As  a  rule,  this  can  be  done  at  the  first  trial,  provided  the  in- 
cision be  in  the  proper  place. 

Ligament  Carriers. 

These  consist  of  flat  needle-like  instruments,  employed  as  carriers,  with 
which  the  fascia  may  be  perforated  and  the  ligament  drawn  through  the 
opening. 


Figure  1182.     Frank's  Ligament  Carrier  for  Alexander's  Operation. 

Frank's  Ligament  Carrier  for  Alexander's  Operation,  as  pictured  in  fig- 
ure 1182,  is  a  flat  curved,  blunt- pointed  needle,  with  a  self-closing  eye,  the 
latter  in  loop  form  and  of  a  size  sufficiently  large  to  engage  and  carry  a 
round  ligament.  It  is  employed  by  piercing  the  fascia  from  ^  to  ^  inch 
from  the  lower  angle  of  the  fascial  incision.  The  needle  eye  is  opened  with 
the  thumb  and  finger,  and  the  ligament  slipped  into  the  loop,  the  latter 
being  closed  by  the  self-action  of  the  spring.  As  this  forms  a  perfect  joint 
without  shoulders,  the  needle  with  the  ligament  may  be  easily  drawn 
through  the  fascia,  leaving  an  opening  sufficiently  large  to  obviate  the  dan- 
ger of  strangulation. 

LOCAL  TREATMENT. 

The  principal  methods  of  local  treatment  consist  of  tamponing,  irriga- 
tion, topical  applications  and  electricity. 

Tamponing. 

This  procedure  described  on  page  475  requires  no  further  illustration 
here.  It  may  be  used  as  a  base  for  medication,  or  to  secure  drainage,  and 
may  be  either  vaginal  or  uterine.  Among  the  many  forms  of  instruments 
used  to  introduce  tampons  those  of  the  forceps  type  are  usually  preferred. 

Irrigation. 

Vaginal  Irrigation  may  be  secured  with  almost  any  kind  of  fountain  or 
bulb  syringe,  or  with  an  ordinary  irrigating  apparatus.  While  many  forms 
of  pipes,  nozzles,  etc.,  are  in  the  market,  it  is  doubtful  whether  any  possess 
advantages  over  the  ordinary  vaginal  pipes,  found  in  common  syringes. 


510  GYNECOLOGICAL    SURGERY. 

Uterine  Irrigation  requires  special  discharge  pipes.  They  are  usually 
called  douches.  As  a  rule,  they  not  only  furnish  means  for  conducting  the 
inflowing,  but  the  outgoing  current  as  well. 


Figure  1183.    Kelly's  Uterine  Douche. 

Kelly's  Uterine  Douche,  as  exhibited  in  figure  1183,  consists  of  a  double- 
curved  injection  pipe,  about  12  inches  in  length,  the  uterine  portion  of 
which  is  surrounded  by  an  outer  cylinder,  by  which  a  double  channel  is  se- 
cured, the  inner  forming  the  inlet,  and  the  other  the  outflow  pipe.  By 
means  of  perforations  in  the  tip  of  the  outer  tube  the  stream  is  converted 
into  sprays  or  jets.  Long  lateral  fenestrae  in  the  rear  of  the  tip  permit  the 
current  to  pass  into  the  chamber  of  the  outer  tube,  while  an  opening  in  the 
lower  end  of  the  same  tube  permits  the  fluid  to  pass  into  the  vagina.  That 
the  instrument  may  be  easily  cleansed,  the  outer  cylinder  is  divided  length- 
wise into  halves,  the  two  pieces  being  secured  at  the  tip  by  means  of  pro- 
jections passing  within  a  collar,  and  at  the  rear  with  a  screw  nut.  A  collar 
at  the  proximal  end  permits  the  attachment  of  an  irrigating  tube,  while  lat- 
eral rings  form  a  handle  for  manipulation. 


Figure  1184.    Bozeman's  Uterine  Douche. 

Bozeman's  Uterine  Douche,  as  shown  in  figure  1184,  differs  from  the 
pattern  of  Kelly  in  that  the  parts  are  not  separable  for  cleansing,  neither  is 
it  arranged  to  discharge  the  injected  fluid  in  the  form  of  jets.  While  this 
pattern  has  been  generally  adopted,  it  appears  deficient  because  the  fluid 
passes  into  the  body  of  the  fundus  through  the  long  f  enestra,  from  which  it 
escapes  by  gravitation.  As  the  return  channel  in  instruments  of  this  class 
is  larger  than  the  inlet,  the  instrument  does  not  appear  to  furnish  means  for 
thorough  irrigation  of  the  uterine  cavity. 


Figure  1185.    Leonard's  Dilating  Douche. 

Leonard's  Dilating  Douche,  as  depicted  in  figure  1185,  overcomes  the 
objection  raised  against  the  ordinary  pattern  of  Bozeman,  as  the  injecting 
fluid  finds  its  exit  into  the  uterine  body  in  the  shape  of  numerous  jets, 
through  small  openings  in  the  tip  of  the  instrument.  In  general  shape  it 
corresponds  with  the  pattern  formerly  described,  except  that  instead  of  the 
double  canula,  or  outer  chamber,  it  is  provided  with  two  wire-like  expand- 


TOPICAL    APPLICATIONS. 


511 


ing  blades,  controlled  by  screw  power,  in  such  a  manner  that  after  the 
instrument  is  introduced,  it  may  be  expanded  to  the  full  extent  of  the  cer- 
vical canal.  As  the  space  between  the  canula  and  the  blades  is  ample  for 
the  escape  of  the  injecting  fluid,  the  instrument  meets  every  requirement. 
It  is  supplied  with  a  collar  for  the  attachment  of  a  rubber  hose. 


Figure  1186A.    Kelly's  Large  Double-Channel  Irrigator. 

Kelly's  Large  Double-Channel  Irrigator,  as  exhibited  in  figure  n86A, 
consists  of  a  metallic  tube,  about  No.  36  French  scale,  the  lumen  of 
which  is  divided  by  a  partition  into  two  semi-circular  sections.  The 
whole  is  curved  in  its  distal  third  to  an  angle  of  about  160°.  At  its  proxi- 
mal end  the  tube  is  bifurcated,  one  section,  the  inflow  tube,  extending  in  a 
straight  line,  the  other,  the  outgoing,  curved  downwards.  The  tip  of  the 
inflow  tube  presents  large  fenestrae,  the  partitions  between  each  opening 
being  of  wire,  the  terminals  of  which  are  securely  fastened  into  a  flat  but- 
ton that  forms  the  extreme  end  of  the  instrument.  The  openings  leading 
into  the  outflow  tube  are  similarly  constructed  and  i  J^  inches  or  more  in 
length,  thus  supplying  a  large  canal  without  danger  of  obstruction.  It  is 
employed  for  irrigating  the  uterus,  especially  above  the  narrow  portion,  in 
cases  of  stricture. 


Figure  1186.    Skene's  Reflex  Douche. 


Skene's  Reflex  Douche,  as  illustrated  by  figure  1186,  consists  of  a  hard 
rubber  catheter,  slightly  curved  at  the  tip  and  provided  with  external  lateral 
grooves  or  troughs  extending  along  the  portion  of  the  catheter,  that  when 
in  use  is  within  the  uterine  cavity.  Small  lateral  openings  in  the  tip  of 
the  instrument  allow  the  injected  fluid  to  escape  in  the  form  of  jets,  while 
the  grooves  above  referred  to  permit  a  return  flow  along  the  body  of  the 
instrument. 

Topical  Applications. 

These,  as  a  rule,  require  a  speculum,  figure  998;  tenaculum,  figure  1019 
and  applicator.  The  latter,  if  for  intra-uterine  work,  may  require  the 
use  of  a  cervical  speculum. 

Applicators. 

These  may  be  of  various  forms,  depending  on  the  nature  of  the  medica- 
ments and  point  of  application.  Besides  the  various  patterns  of  plain  ap- 
plicators, they  include  caustic  holders,  pipettes,  etc. 


512 


GYNECOLOGICAL    SURGERY. 


Emmet's  Plain  Applicator,  as  portrayed  in  figure  1187,  consists  of  a 
flexible,  copper,  silver-plated  rod,  its  distal  half  flattened,  and  its  proximal 
end  attached  to  a  suitable  handle. 


Figure  1187.    Emmet's  Plain  Applicator. 

Fitch's  Applicator,  as  defined  in  figure  1188,   differs  from  the  pattern 
of  Emmet,  last  above  described,  in  being  provided  with  a  spiral   elastic 


Figure  1188.    Fitch's  Applicator. 

sheath,  by  which  a  medicated  or  soiled  swab  may  be  detached  from  the  tip 
of  the  instrument  without  contaminating  the  fingers. 

Figure  1189.     Playfair's  Applicator. 

Playfair's  Applicator  consists  of  a  long  metal  curved  tip,  that  in  general 
form  resembles  the  point  of  Sims'  uterine  probe.  The  tip  is  usually 
of  silver  or  aluminum.  The  instrument,  as  shown  by  figure  1189,  is  used 
for  the  application  of  such  medicaments  as  may  be  absorbed  and  held  by 
cotton.  The  tip  of  the  probe  is  smooth,  and  a  roughened  section,  about 
an  inch  from  the  point,  assists  in  holding  the  cotton  pledget  in  position. 

Skene's  Instillation  Tube,  as  set  forth  in  figure  1190,  consists  of  a  glass 
pipette,  about  6  inches  in  length,  slightly  curved  at  the  tip.  A  rubber  nip- 
ple attached  to  the  proximal  end  furnishes  exhaust  means  by  which  fluid 
may  be  drawn  into  and  expelled  from  the  tube.  It  is  employed  for  the 
application  of  fluids  to  the  cervical  canal. 


Figure  1190.    Skene's  Instillation  Tube. 

Caustic  Holders. 


.  These  are  constructed  in  many  forms,  depending  on  the  nature  of  the 
caustic  employed.  Caustic,  in  the  form  of  sticks,  may  be  held  by  clamps, 
either  as  plain  forceps,  or  blades  controlled  by  springs,  or  closed  by  sliding 
rings.  If  in  the  form  of  paste,  some  kind  of  cup  is  necessary,  while  if  fused 
and  re-crystallized,  a  flat  spatula  form  may  be  utilized. 


Figure  1191.     Byford's  Caustic  Holder. 

Byford's  Caustic  Holder,  as  represented  by  figure  1191,  is  intended  for 
clamping  and  applying  stick  caustic.  It  consists  of  a  slender  wire  of  pure 
silver,  terminating  in  an  open-end  slotted  cylinder.  The  latter  is  sur- 
rounded by  a  closing  ring,  so  adjusted  that  a  piece  of  caustic  may  be  placed 
within  the  jaws  of  the  cylinder,  and  these  closed  and  firmly  held  against  the 


ELECTRODES. 


513 


caustic  stick  by  means  of  a  ring.  The  silver  shaft  is  inserted  in  a  hard  rub- 
ber plug,  supplied  with  a  screw  at  each  end  A  cylindrical  extension,  or 
handle,  forms  an  instrument  some  10  or  12  inches  in  length.  The  handle 
is  hollow  and  so  arranged  that  the  applicator  may  be  reversed  and  securely 
fastened  within. 

Cervical  Specula. 

These  consist  of  tubes  or  bi-valve  instruments,  mounted  on  shanks,  or 
handles,  of  sufficient  length  to  admit  of  introduction  through  or  by  means 
of  a  vaginal  speculum.  They  are  little  employed  except  as  a  shield  to  pre- 
vent instrumental  injury  to  the  cervix,  or  misapplication  of  caustics  in- 
tended for  points  within  the  f undus. 


Elliott's  Intra-Uterine  Speculum. 


Figure  llfti 


Elliott's  Cervical  Speculum  consists  of  two  slender  tubular  blades, 
hinged  upon  their  lower  border.  They  may  be  opened  or  spread  apart  by 
means  of  a  scissors  handle  and  a  compound  lever.  The  handles  of  the  instru- 
ment are  curved  downward,  that  the  hand  of  the  operator  may  not  obstruct 
the  field  of  vision.  When  closed,  the  diameter  of  the  blades  is  about  7,  and 
when  open,  about  1 2  millimeters.  The  instrument  is  well  traced  by  figure 
1192. 


GYNECOLOGICAL  ELECTRODES. 

The  various  electrical  currents,  when  employed  for  therapeutic  treat- 
ment, require  the  use  of  electrodes,  that  the  current  may  be  conducted  in 
the  proper  manner.  They  may  be  plain,  insulated  or  bipolar,  and  are  used 
in  the  vagina,  uterus  or  urethra. 


Figure  1193.    Plain  Vaginal  Electrode. 


Figure  1194.    Insulated  Vaginal  Electrode. 

The  Metallic  Electrodes,  exhibited  in  figures  1193  and    1194,  are   each 
about  6  inches  in  length  and  ^  of  an  inch  in  diameter.     One  presents  a 


Figure  1195.    Curved  Vaginal  Electrode. 

metallic  surface  throughout  its  entire  length,  while  the  other  is  insulated 
with  hard  rubber,  excepting  along  its  outer  two-fifths. 


514 


GYNECOLOGICAL    SURGERY. 


The  Curved  Vaginal  Electrode,  pictured  in  figure  1195,  differs  from  the 
insulated  pattern  before  described,  as  the  shaft  is  slightly  curved  at  the 
junction  of  the  first  and  middle  thirds. 

Palmer's  Vaginal  Douche  Electrode,  as  sketched  in  figure  1196,  consists 
of  a  cylinder  about  9  inches  in  length,  the  outer  surface  of  which,  with  the 
exception  of  about  2  inches  of  its  distal  end,  is  covered  or  insulated  with 
hard  rubber.  It  is  not  only  provided  with  means  for  connection  with  an 
electric  battery  but  with  a  double  current  douche  tube  by  which  a  stream 


Figure  1196.    Palmer's  Vaginal  Douche  Electrode. 

of  water  may  be  passed  through  the  instrument.     During  the  application 
of  the  current  the  water  may  be  hot  or  cold  as  desired. 


Figure  1197.    Bipolar  Vaginal  Electrode. 


The  Bipolar  Vaginal  Electrode,  exhibited  in  figure  1197,  illustrates  one 
of  the  many  forms  in  which  appliances  of  this  kind  may  be  secured.  The 
insulation  may  include  any  portion  of  the  electrode,  which  may  be  divided 
transversely,  longitudinally  or  in  zones. 


Figure  1198.    Uterine  Electrode. 

The  Uterine  Electrode,  shown  by  figure  1198,  consists  of  a  bell-shaped 
tip  with  outer  insulated  surface,  attached  to  a  rubber  covered  shaft.  As 
the  inner  surface  of  the  cup  alone  presents  a  conducting  surface,  a  current 
may  be  conducted  to  the  uterus.  Various  sizes  are  manufactured,  those 
usually  obtainable  being  ^  inch,  i  inch  and  i%  inches  across  the  cup. 


Figure  1199.    Goelet's  Vaginal  Clay  Electrode. 

Goelet's  Vaginal  Clay  Electrode  consists  of  a  slender  metallic  rod  with 
an  outer  sheath  of  hard  rubber,  the  vaginal  end  of  which  is  inserted  in  a 
short  oval  mass  of  clay,  the  latter  held  in  place  by  an  outer  cover  of  cham- 
ois. It  can  be  employed  only  after  thorough  saturation  in  water.  It  is 
represented  in  figure  1199. 


ELECTRICAL  TREATMENT. 


515 


Martin's  Double  Copper  Electrode,  consists  of  a  long  shaft  or  handle, 
each  end  of  which  is  curved  in  the  form  of  an  intra- uterine  electrode.  The 
central  portion  of  the  instrument,  as  shown  in  figure  1200,  is  provided  with 


Figure  1200.    Martin's  Double  Copper  Electrode. 

a  sliding  insulated  handle,  by  which  the  instrument  is  manipulated.  For 
general  electrical  treatment  and  for  purposes  of  dilatation,  they  can  be  pro- 
cured with  any  sizes  of  tips  desired. 


Figure  1201.     Flexible  Intra-Uterine  Electrode. 

The  Flexible  Intra-Uterine  Electrode,  exhibited  in  figure  1201,  consists 
of  an  elastic  web  catheter,  within  which  a  copper  wire  is  employed  to  con- 
duct the  electrical  current.  The  uterine  portion  of  the  instrument  is  of 
spiral  wire,  with  a  copper  core,  ensuring  flexibility.  The  extreme  tip  is  of 
hard  rubber.  A  soft  rubber  sliding  handle  permits  of  proper  manipulation. 


Figure  1202.    Goldspohn's  Intra-Uterine  Electrode. 

Goldspohn's  Intra-Uterine  Electrode,  as  exhibited  in  figure  1202,  is 
shaped  like  an  ordinary  uterine  sound.  It  consists  of  an  insulated  shaft, 
the  uterine  or  curved  portion  of  which  consists  of  a  copper  cylinder  that 
tapers  slightly  to  the  end. 


TRLMX-GREENE-CO. 


Figure  1203.     Neiswanger's  Block  Tin  Electrode. 

Neiswanger's  Block  Tin  Electrode,  as  pictured  in  figure  1203,  differs 
from  the  pattern  of  Goldspohn,  the  curved  portion  of  the  stem  being  of 
block  tin,  tipped  at  the  extreme  end  with  hard  rubber. 


Figure  1204.    Bipolar  Ovarian  Electrode. 

The  Bipolar  Ovarian  Electrode,  portrayed  in  figure  1204,  is  made  of 
two  hard  rubber,  covered  conducting  rods,  each  insulated  from  the  other, 
arranged  for  connection  with  one  of  the  poles  of  an  electric  battery, 
and  terminating  in  a  flat,  sponge-covered  disc  about  i%  inches  in  diam- 
eter. They  are  employed  not  only  for  making  electric  applications  to  the 
ovaries,  but  are  occasionally  used  by  ophthalmologists  in  treating  diseases 
of  the  eye,  as  the  distance  between  the  two  discs  and  their  size  render 
them  well  adapted  for  this  purpose. 


516 


GYNECOLOGICAL    SURGERY. 


UTERINE  DISPLACEMENT- 

Malpositions  of  the  uterus  frequently  require  replacement,  and  the  appli- 
cation of  supports  or  braces,  by  means  of  which  its  maintenance  in  a  nor- 
mal position  is  attempted.  The  most  common  of  these  deviations  are: 
Anteversion,  retroversion,  prolapsus,  anteflexion,  retroflexion,  inversion. 

In  the  treatment  of  these  displacements,  the  uterus  in  certain  cases  may 
be  replaced  by  digital  and  manual  manipulation,  or  by  employing  special 
instruments  called  repositors.  The  latter,  though  once  in  common  use, 
are  now  little  employed. 

Uterine  Bepositors. 

These  consist  of  levers  employed  to  replace  a  uterus  when  out  of  normal 
position. 


Figure  1205.    Elliott's  Uterine  Repositor. 

Elliott's  Uterine  Repositor,  as  set  forth  in  figure  1205,  from  a  mechan- 
ical standpoint,  would  seem  an  ideal  instrument.  Notwithstanding  its 
apparent  perfect  adaptability  to  meet  every  requirement  and  its  former 
popularity,  it  is  now  seldom  employed.  It  consists  of  two  flat  metallic 
bands,  united-at  their  distal  points  by  soldering  or  riveting  them  together, 
and  both  contained  within  a  soft  elastic  web  catheter.  This  catheter,  at 
its  proximal  end,  is  attached  to  a  metallic  cylinder,  provided  with  ring 
handles  and  screw  mechanism,  of  such  a  nature  that  by  turning  a  milled 
nut  attached  to  the  lateral  bars  previously  referred  to  in  one  direction 
one  bar  is  lengthened,  while  the  other  is  shortened,  thus  curving  the  tip  of 
the  instrument  in  the  direction  of  the  shortened  bar.  By  reversing  the 
movement  of  the  milled  nut,  the  reverse  condition  is  obtained  and  the 
instrument  curved  in  an  opposite  direction.  The  objections  to  the  instru- 
ment are  that  it  is  easily  broken,  difficult  of  repair  and  that  it  furnishes  no 
means  for  determining  the  extent  of  curvature  or  correcting  force  applied 
at  any  time. 


o 


Figure  1206.    Sims'  Uterine  Repositor. 

Sims'  Uterine  Repositor,  as  sketched  in  figure  1206,  consists  of  a  handle 
and  hollow  shaft,  the  latter  terminating  in  a  slotted  head  within  which  a 
small  wheel  is  secured  by  means  of  a  suitable  shaft.  By  means  of  a  screw 
attachment,  intra-uterine  stems  of  proper  length  and  shape  are  attached  to 


UTERINE    DISPLACEMENTS. 


517 


the  periphery  of  the  wheel.  The  body  of  the  instrument  is  tubular  in 
form,  in  the  center  of  which  a  shaft  pushed  forward  by  a  spiral  spring  and 
retracted  by  a  ring  handle  is  caused  to  actuate.  Holes  bored  in  the  outer 
margin  of  the  wheel  receive  the  distal  end  of  the  shaft.  While  being 
inserted,  the  shaft  is  withdrawn  from  contact  with  the  wheel  and  the  stem 
introduced  within  the  uterine  body.  When  in  position,  the  operator  may 
attempt  replacement  by  leverage.  After  the  lever  is  moved  in  the  proper 
direction,  as  far  as  the  surrounding  parts  will  admit,  while  the  uterus  is 
held  by  manual  force,  the  shaft  in  the  tube  may  be  withdrawn,  the  handle 
moved  backward  until  contact  with  the  next  opening  in  the  wheel  is  made 
with  the  shaft,  when  further  correction  may  be  made. 


Figure  1207.    Ludlam's-Guernsey's  Uterine  Repositor. 


Ludlam's-Guernsey's  Uterine  Repositor  consists  of  a  double  curved  stem, 
one  end  of  which  terminates  in  an  acorn-shaped  bulb,  the  other  in  a  loop 
about  i  inch  in  diameter.  As  the  ends  of  the  instrument  are  of  different 
curves,  it  may  be  used  in  various  cases.  It  is  intended  as  an  aid  to  finger 
manipulation  in  uterine  replacements,  and  is  well  traced  in  figure  1207. 


Figure  1208.    Emmet's  Extra-Uterine  Repositor. 


Emmet's  Extra-Uterine  Repositor,  as  shown  by  figure  1208,  consists  of 
a  small  head  in  hour-glass  form  attached  to  a  hard  rubber  handle,  the  whole 
forming  an  instrument  much  resembling  an  ordinary  mallet.  The  depres- 
sion in  the  center  of  the  head  forms  a  good  contact  with  the  uterine  body, 
the  instrument  being  used  as  a  lever  to  assist  in  replacement. 


IRUAX-EREENE-CU. 


Figure  1209.     Kelly's  Rotator. 

Kelly's  Rotator,  as  defined  in  figure  1209,  consists  of  a  slender  tapering 
shaft,  terminating  in  a  needle-like  point,  provided  with  cross  bars  in  T- 
form,  that  prevent  its  introduction  beyond  a  necessary  depth.  It  is  em- 
ployed as  an  elevator  or  replacer  by  penetrating  the  cervix  and  using  the 
instrument  to  push  or  rotate  the  uterus  on  its  hinged  supports. 

Pessaries. 

The  uterus,  after  replacement,  may  be  oftimes  held  in  position  by  sup- 
ports called  pessaries.  Owing  to  the  manifold  conditions  encountered  by 
the  practitioner,  nearly  every  case  of  which  may  require  a  special  appliance, 
no  one  list  of  pessaries  can  be  formulated  for  any  single  class  of  displace- 
ments. Furthermore,  many  operators  advise,  for  ascertain  malposition,  a 
pessary  that  some  one  else  prescribes  for  a  different  purpose. 

Generally  speaking,  the  use  of  pessaries  has  fallen  into  more  disrepute, 


518  GYNECOLOGICAL    SURGERY. 

we  believe,  on  account  of  their  misuse  than  because  they  are  not  indicated 
in  certain  conditions.  It  is  claimed  that  their  use  is  admissible  in  all  cases 
where  replacement  is  possible  and  retention,  by  their  aid,  secured  with 
comfort. 

It  is  well  known  that,  even  with  a  large  assortment  of  shapes  and  sizes, 
a  perfectly  fitting  pessary  can  be  secured  only  after  many  trials  and  much 
labor.  As  a  rule,  the  better  class  of  gynecologists,  like  the  dentist  in  pre- 
paring a  set  of  teeth,  shape  each  instrument  to  fit  the  particular  case  to 
which  it  is  applied.  Such  pessaries  require  frequent  changes  and  readjust- 
ments. After  a  perfect  fit  has  been  secured  with  a  temporary  pessary,  a 
permanent  one,  usually  better  adapted,  can  be  obtained  from  the  instru- 
ment maker  who  may  use  the  first  one  as  a  model  for  construction. 

Generally  speaking,  there  are  four  kinds  of  pessaries  that  may  be 
moulded  as  wanted  and  used  as  primary  supports.  They  are  all  in  ring 
form  and  manufactured  either  from  rubber,  celluloid,  block  tin  or  copper 
wire,  the  latter  covered  with  soft  rubber. 

Usually,  these  instruments  are  manufactured  from  hard  rubber,  because 
of  its  lightness  and  the  high  polish  that  may  be  given  it.  Pessaries  from 
this  material  may  be  moulded  into  any  desired  form  by  first  covering  them 
with  oil  or  petrolatum  and  holding  them  in  the  flame  of  a  spirit  lamp  until 
softened.  The  grease  covering  the  instrument  prevents  the  rubber  from 
taking  fire.  When  softened  by  the  heat,  the  pessary  may  be  moulded  in 
the  fingers  as  desired.  To  avoid  injuring  the  texture  of  the  rubber  it 
should  be  heated  gradually.  As  water  on  the  surface  will  cause  the  rubber 
to  crack,  an  anhydrous  grease  should  be  employed  as  a  covering.  A  gas  jet 
may  be  utilized  instead  of  a  spirit  lamp,  but  greater  care  must  be  exercised, 
as  owing  to  the  higher  degree  of  heat  and  lesser  area  covered  by  the  flame, 
there  is  more  danger  of  burning  the  rubber.  Boiling  water  may  be  used 
when  a  pessary  requires  molding  in  all  its  parts.  Gloves  are,  however, 
necessary  for  manipulation. 

If  a  hard  rubber  ring  is  not  at  hand,  almost  any  of  the  ordinary  forms, 
such  as  the  Albert  Smith,  Hodge,  etc.,  may  be  deprived  of  their  bow  and 
sigmoid  curves  by  immersion  in  boiling  water.  Ring  pessaries  of  celluloid 
are  largely  used  in  Great  Britain  and  on  the  Continent,  because  it  is 
claimed  that  this  material  can  be  much  more  easily  moulded  than  hard 
rubber.  As  the  difference  in  expense  is  not  great,  this  material,  if  all 
that  is  claimed  for  it  be  true,  may  also  become  popular  in  this  country. 
Many  operators  advise  the  use  of  pessaries  made  from  block  tin.  This  is 
an  alloy  of  lead  and  tin,  and,  while  it  may  be  easily  moulded  with  the 
fingers,  is  firm  enough  to  answer  all  the  purposes  of  the  pessary. 

Pessaries  made  by  covering  a  copper  wire  with  soft  rubber,  at  one  time 
enjoyed  quite  a  large  sale,  because  of  the  readiness  with  which  they  could 
be  changed  to  suit  any  existing  condition.  They  have  fallen  into  disuse, 
however,  except  for  temporary  use,  either  because  soft  rubber,  unless  it 
has  a  velvet  surface,  is  unfit  for  long  contact  with  mucous  surfaces,  or 
because  experience  has  proved  that  it  is  not  possible  to  curve  pessaries  of 
this  class  without  creating  folds  or  creases  in  the  soft  rubber  mass.  As 
these  four  forms  of  ring  pessaries  can  be  obtained  in  any  desired  size,  the 
surgeon  may  improvise  pessaries  for  almost  any  condition  if  provided  with 
a  sufficient  assortment. 

Anteversion  Pessaries. 

Graily  Hewitt's  Pessary,  as  employed  for  anteversion,  consists  of  two 
oval  rings  in  V-shape,  united  at  their  apex  by  a  bridge  with  a  well- 


PESSARIES. 


519 


rounded  upper  surface.  The  rings,  as  indicated  by  figure  1210,  each 
present  a  concave  outer  face,  all  the  parts  being  constructed  without 
sharp  angles. 


Figure  1210.     Graily  Hewitt's  Pessary. 


Figure  1211.    Thomas'  Anteversion  Pessary. 


Thomas'  Double  Bow  Anteversion  Pessary,  as  outlined  by  figure  1211,  con- 
sists of  two  bow  or  U-shaped  parts  united  by  a  hinged  joint.  One,  the 
upper,  from  its  tips  backward,  widens  into  a  band-like  form,  the  outer  mar- 
gin of  which  is  slightly  concave,  where  it  presses  against  the  uterus.  The 
bow  upon  the  under  side  is  curved  from  a  plain  rod  and  is  slightly  larger 
than  its  mate.  When  applied,  this  rests  with  the  wider  or  horseshoe  portion 
against  the  anterior  surface  of  the  uterus,  with  the  lower  bow  projecting 
forward  against  the  anterior  vaginal  wall. 


Figure  1212.    Thomas'  Single  Bow  Anteversion         Figure  1213.     Gehrung's  Anteversion  Pessary. 
Pessary. 

• 

Thomas'  Single  Bow  Anteversion  Pessary,  as  shown  by  figure  1212,  con- 
sists of  a  base  similar  in  form  to  the  Albert  Smith  pessary  (figure  1216), 
to  the  upper  face  of  which  is  attached  a  loop  of  bow  form.  This  bow  is 
attached  at  a  point  about  one-third  of  the  distance  between  the  wide  and 
pointed  ends  of  the  pessary,  being  nearer  to  the  former.  The  instrument 
may  be  procured  in  a  large  variety  of  sizes.  When  in  use,  both  bows  are 
raised  until  they  rest  against  the  vaginal  wall,  one  in  front  of  and  the  other 
behind  the  cervix. 

Gehrung's  Anteversion  Pessary,  as  will  be  seen  by  consulting  figure  1213, 
consists  of  a  ring  curved  almost  in  double  S-form,  presenting  some- 
what the  shape  of  two  bows  and  two  horseshoes.  When  in  place,  the  two 
uniting  bows  rest  on  the  posterior  vaginal  wall,  while  the  two  horseshoes 
embrace  the  cervix  anteriorly. 

Anteflexion  Pessaries. 

This  complication  may,  in  many  cases,  particularly  if  of  a  mild  type,  be 
treated  with  the  same  pessaries  as  are  employed  for  anteversion.  Stem  pes- 
saries, which  have  been  advised  by  some  authors,  are  by  most  operators 
considered  dangerous. 


520 


GYNECOLOGICAL    SURGERY. 


Gehrung's   Anteflexion   Pessary,  as   outlined   in   figure    1214,  does   not 
differ  in  general  form  from  the  pattern  last  described.      To  correct  the 


Figure  1214.    Gehrung's  Anteflexion  Pessary. 


Figure  1215.    Thomas'  Anteflexion  Pessary. 


flexion,  the  inner  surfaces  of  the  upper  horseshoe  are  united  with  a  trough- 
shaped  floor,  against  which  the  uterus  may  rest. 

Thomas'  Anteflexion  Pessary,  as  it  appears  in  figure  1215,  consists  of  a 
horseshoe  form,  the  ends  of  which  are  hinged  to  the  outer  surface  of  a  ring. 
The  latter  is  of  heavy  construction  with  a  perpendicular  shaft  projecting 
from  its  upper  surface  at  a  point  midway  between  the  hinged  arms  of  the 
bow  previously  referred  to.  This -upright  terminates  in  across  bar,  the 
whole  being  in  T-form.  The  top  of  the  cross  bar  rests  on  a  level  with 
or  slightly  above  that  of  the  apex  of  the  bow. 

Retroversion  Pessaries. 

This,  the  most  common  of  misplacements,  is  usually  treated  with  pes- 
saries of  simple  design.  Among  the  vast  number  constructed  for  this  use, 
we  will  only  illustrate  a  few  of  the  more  common  varieties. 


Figure  1216.    Albert  Smith's  Retroversion  Pessary. 


Figure  1217.    Hodges'  Bow  Pessary. 


Albert  Smith's  Retroversion  Pessary  consists  of  two  lateral  sigmoids, 
united  at  their  terminals  by  bows,  one  wide  and  rounding,  the  other  short 
and  more  sharply  curved.  As  well  sketched  in  figure  1216,  the  pessary 
narrows  from  above  downward  as  do  the  vaginal  walls.  This  pattern 
may  be  obtained  in  a  great  variety  of  sizes. 

Hodges'  Retroversion  Bow  Pessary,  as  depicted  in  figure  1217,  consists 
of  an  oval  ring  curved  on  the  flat.  It  differs  from  the  Albert  Smith,  in 
not  being  as  sharply  curved  at  its  extremities.  Like  the  latter,  it  may  be 
obtained  in  a  great  variety  of  sizes. 

Gehrung's-Smith's  Retroversion  Pessary,  as  delineated  in  figure  1218, 
differs  from  the  Albert  Smith  pattern,  in  that  the  larger  bow  is  replaced 
with  a  cross  bar  slightly  curved  inward.  They  are  usually  manufactured 
from  heavy  rubber,  but  are  not  usually  found  in  a  great  variety  of  sizes. 


PESSARIES.  521 


Byford's  Modified  Smith's  Retroversion  Pessary  differs  from  the  Albert 
Smith,  in  that  the  beak  or  sharp-point  extremity  is  more  abruptly  curved 
on  the  edge,  while  that  portion  forming  the  wide  bow  is  sharply  curved 


Figure  1218.    Gehrung's-Smith's  Retroversion  Figure  1219.     Byford's  Modified  Smith's  Retro- 

Pessary,  version  Pessary. 

upward  and  inward  to  the  extent  of  nearly  three-fifths  of  the  arc  of  a 
circle.  The  general  form  is  shown  in  figure  1219.  This  pessary,  like 
the  one  last  described,  can  usually  be  found  in  only  a  limited  number 
of  sizes. 

Betroflexion  Pessaries. 


Figure  1220.    Thomas'  Retro-         Figure  1221.    Emmet's  Pessary  for  Figure  1222.     Fowler's  Pessary 

flexion  Pessary.  Retroflexion.  for  Retroflexion. 

Thomas'  Retroflexion  Pessary,  as  defined  in  figure  1220,  differs  from 
that  of  Albert  Smith  in  that  it  is  narrower  in  proportion  to  its  length, 
while  the  greater  bow  is  enlarged  to  a  bulb-like  form.  As  this  pattern  is 
more  largely  employed  for  this  complication  than  any  other,  it  is  manu- 
factured in  a  great  variety  of  sizes. 

Emmet's  Pessary  for  Retroflexion,  as  represented  by  figure  1221,  differs 
from  the  pattern  of  Smith,  in  being  less  pointed  at  its  anterior  margin. 
In  shape  it  may  be  said  to  be  midway  between  the  patterns  of  Smith 
and  Hodge.  It  should  be  constructed  from  heavy  rubber,  thus  presenting 
a  large  contact  surface,  less  liable  to  become  embedded  in  soft  tissues. 

Fowler's  Pessary  can  be  best  understood  by  consulting  figure  1222. 
The  upper  and  outer  margins  of  this  pessary  are  almost  identical  with 
those  of  the  Albert  Smith  pessary.  It  differs  from  the  latter,  in  that  the 
space  between  the  bows  is  filled,  the  upper  surface  presenting  a  bowl-like 
shape  but  without  bottom.  It  has,  therefore,  a  rim  or  collar-like  form, 
the  lower  opening  being  much  smaller  than  the  upper.  A  small  opening  in 


522 


GYNECOLOGICAL    SURGKRY. 


the  sharp  angle  of  the  instrument  admits  the  finger  tip,  by  means  of  which 
the  pessary  is  manipulated.     It  may  be  obtained  in  five  sizes. 

This  displacement,  like  anteflexion,  may  be  treated  with  stem  pessaries. 
Without  advising  their  use,  we  exhibit  two  of  the  more  common  patterns. 


Figure  1223.    Plain  Hard  Rubber  Stem  Pessary.  Figure  1224.    Jackson's  Elastic  Stem  Pessary. 


Plain  Hard  Rubber  Stem  Pessaries  for  flexions  may  be  obtained  in 
various  forms.  The  most  common,  as  indicated  by  figure  1223,  consists  of 
a  plain  cylindrical  stem  attached  to  a  small  disc  or  cup,  by  means  of  which 
the  instrument  is  manipulated.  They  usually  vary  in  length  from  i  ^  to 
2^4  inches. 

Jackson's  Elastic  Stem  Pessary,  as  traced  in  figure  1224,  consists  of  a 
soft  rubber  conical  stem,  terminating  in  a  bulb-shaped  tip ;  a  cylindrical 
disc-like  base  allows  manipulation.  They  are  usually  of  four  lengths, 
JM>  2>  2/^  aQd  2%  inches,  respectively.  Owing  to  their  elasticity  they 
exert  a  gentle,  and,  it  is  said,  efficient  pressure  in  a  corrective  direction. 
Their  inventor  claimed  for  them  great  efficiency,  and  avoidance  of  the 
dangers  attending  the  use  of  hard  rubber  stem  pessaries. 

Prolapsus  Pessaries. 

Many  forms  of  appliances  have  been  advised  for  the  treatment  of  pro- 
lapsus. They  vary,  from  the  styles  of  pessaries  previously  described,  to 
stems  terminating  in  cups,  the  whole  being  supported  by  elastic  cords 
attached  to  abdominal  belts.  Many  authors  advise  inflated  bags  or  rings 
that  rely  for  support  upon  lateral  pressure  against  the  vaginal  walls. 


Figure  1225.    Pear  Shaped  In- 
flating Pessary. 


Figure  1226.    Inflated  Annujar 
Ring  Pessary. 


Figure  1227.    Spiral  Ring  Pessary. 


The  Pear-Shaped  Inflating  Pessary,  portrayed  by  figure  1225,  consists 
of  a  pear-shaped  bag  to  which  is  attached  a  rubber  tube,  by  means  of  which 
it  may  be  inflated  to  any  desired  extent.  They  may  be  obtained  in  various 
sizes,  and  of  either  white  or  pure  gum  rubber. 

The  Inflated  Ring  Pessary,  as  described  by  figure  1226,  consists  of  a 
rubber  ring  to  which  is  attached  a  rubber  tube,  by  means  of  which  the  air 
chamber  may  be  inflated.  They  may  be  obtained  in  various  sizes. 

The  Spiral  Ring  Pessary,  the  construction  of  which  is  explained  by 
figure  1227,  consists  of  an  elastic  spiral  ring  surrounded  by  a  heavy  wall 


PESSARIES. 


523 


or  coating  of  soft  rubber.  As  usually  found  in  this  market,  it  is  of  German 
make  and  is  preferred  by  some  operators  to  the  ordinary  watch-spring 
elastic  pessary,  because  of  the  extra  thickness  of  the  ring. 


Figure  1228.    Cutter's  Prolapsus  Pessary. 


Figure  1229.    Mclntosh's  Uterine  Supporter. 


Cutter's  Prolapsus  Pessary,  as  shown  by  figure  1228,  consists  of  a 
curved  stem,  fitting  closely  to  the  perineum  and  extending  within  the  vagina 
where  it  terminates  in  a  cup  or  bowl  of  a  size  suitable  to  receive  the  cervix. 
The  external  portion  of  the  stem  is  attached  to  a  piece  of  soft  rubber  tubing 
suspended  from  a  waist  or  belt,  by  means  of  which  it  is  supported.  Cups 
and  pessaries  of  various  forms  have  been  designed  with  a  support  similar 
to  the  pattern  shown  in  the  illustration. 

Mclntosh's  Uterine  Supporter,  as  will  be  seen  by  referring  to  figure 
1229,  differs  from  the  pattern  of  Cutter,  principally  in  its  method  of  sup- 
port and  the  form  of  body  belt.  The  latter  is  in  the  form  of  an  abdominal 
support  to  which  are  attached,  at  front  and  back,  two  rubber  tubes,  each 
of  which,  at  its  center,  passes  through  small  holes  in  the  base  of  the 
pessary  stem.  This,  because  of  a  claimed  patent,  was  sold  for  many  years 
at  an  exorbitant  price.  As  it  was  supposed  to  be  of  value  in  certain  classes 
of  cases,  and  was  generously  advertised,  it  commanded  a  large  sale.  It 
can  now,  however,  be  purchased  at  a  fair  price. 

Inversion. 

This  malposition,  after  reduction,  may  be  treated  in  the  same  manner  as 
prolapsus.  An  instrument  occasionally  employed  to  assist  replacement  is, 
perhaps,  worthy  of  mention. 


Figure  1230.     White's  Repositor. 

White's  Repositor  consists  of  a  cup,  a  spiral  spring  and  a  breast-piece, 
the  whole  so  arranged  that  elastic  pressure  in  the  proper  direction  may  be 


524 


GYNECOLOGICAL    SURGERY. 


directed  immediately  against  the  cervix  of  the  inverted  organ.  The  cup 
should  be  of  such  a  size  that  it  will  fit  the  cervix,  and  the  spiral  spring 
should  be  so  arranged  that  it  will  not  bend  laterally  to  any  great  extent. 
The  shaft,  though  usually  constructed  with  a  chest-piece  to  rest  against 
the  body  of  the  operator  by  which  proper  force  is  applied,  may  be  of  any 
other  desired  form.  The  mechanism  of  the  apparatus  is  shown  in 
figure  1230. 


BLADDER. 

The  instruments  employed  in  treating  diseases  peculiar  to  the  female 
bladder,  are  nearly  all  described  in  that  portion  of  this  chapter  devoted  to 
'  'Examinations. ' '  Such  appliances  as  refer  to  general  diseases  of  the  bladder 
are  included  in  a  chapter  devoted  to  "Surgery  of  the  Male  Genito-Urinary 
Organs."  Those  which  are  not  referred  to  in  the  sections  before  men- 
tioned, include  those  for  irrigation,  cystocele,  etc. 

Irrigation. 

Irrigation  for  any  reason  necessitates  the  use  of  a  fountain  syringe  or 
other  reservoir  with  suitable  catheters.  The  latter  may  be  either  double 
or  single-current,  the  former  being  usually  preferred.  If  no  better  means 
be  at  hand,  the  physician  may  employ  a  piece  of  rubber  tubing  and  a  small 
funnel  similar  to  the  apparatus  used  for  washing  out  the  stomach. 


Figure  1231.    Kelly's  Glass  Two- Way  Catheter. 

Kelly's  Double-Current  Catheter,  as  shown  by  figure  1231,  consists  of 
a  double-channeled  glass  tube,  each  channel  terminating  at  its  proximal  end 
in  a  single  tube,  the  two  spreading  in  V-form.  Openings  in  the  vesical 
end  of  each  channel  allow  the  in-and-out  flow,  as  shown  by  the  arrow  in 
the  illustration. 

Appliances  for  Cystocele. 

Prolapse  of  the  bladder  may  occasionally  be  relieved  by  the  adjustment 
of  a  specially  devised  truss.  In  the  female,  pessaries  are  sometimes 
employed  instead  of  a  truss. 


Figure  1233.     Cystocele  Truss. 

The   Cystocele  Truss,  sketched  in   figure    1233,  is  only  one   of    many 
patterns  that  may  be  used  for  this  purpose.     Instead  of  the  elastic  band, 


PESSARIES.  525 

it  may  be  constructed  with  a  steel  spring,  as  is  an  ordinary  truss.  The 
pad  in  either  case  should  present  a  flat  concave  surface  over  the  bulging 
mass.  The  brim  of  the  pad  should  be  deflected  outward  in  the  center  of 
its  lower  border,  that  it  may  not  produce  undue  pressure  upon  the  pubic 
arch. 


Figure  12*1.    Skcne's  Sigmoid  Cystocele  Pessary.       Figure  1235.    Skene's  Original  Cystocele  Pessary. 


Skene's  Sigmoid  Cystocele  Pessary,  as  illustrated  in  figure  1234,  resem- 
bles in  general  form  the  pessary  of  Emmet,  differing  only  in  that  the 
lateral  bars  are  enlarged  in  the  form  of  olives,  each  bulb  extending  into 
the  central  opening  of  the  pessary,  at  a  point  slightly  above  its  center. 

Skene's  Original  Cystocele  Pessary,  as  exhibited  in  figure  1235,  con- 
sists of  a  hard  rubber  ring  about  i  ^  inches  in  diameter,  one  side  of  which 
extends  in  a  bridge  or  bow  form,  the  whole  giving  to  the  pessary  a  sig- 
moid  shape.  A  V-shaped  support  connects  the  terminal  end  of  the 
bridge-piece  with  its  base,  as  shown  in  the  illustration. 


CHAPTER  XXIV. 


GENITO-URINARY  SURGERY. 

Surgery  of  the  genito-urinary  organs,  so  far  as  it  comes  within  the 
province  of  this  work,  will  include  instruments  and  appliances  for  opera- 
tions on  the  kidneys,  bladder,  urethra,  prostate,  penis  and  the  scrotum  and 
its  contents. 


SURGERY  OF  THE  KIDNEYS. 

The  instruments  and  appliances  employed  in  renal  surgery  may  be  di- 
vided into  those  for  external  support  for  floating  kidneys,  puncture, 
nephropexy  or  nephrorraphy,  nephrotomy,  nephrolithotomy  and  nephrec- 
tomy. 

Appliances  for  Floating  Kidneys. 

The  discomfort  due  to  movable  and  floating  kidneys  may  be  relieved 
in  many  instances  by  the  application  of  an  abdominal  belt  provided  with 
an  air  or  water  pad  so  adjusted  as  to  exert  compression  over  or  upon  the 
wandering  organ. 


Figure  1236.     Cunning's  Kidney  Pad. 

Dunning's  Kidney  Pad,  as  illustrated  by  figure  1236,  is  an  elastic  rubber 
air  cushion  2^  to  3^  inches  in  diameter,  and  when  inflated,  from  ^  to  i 
inch  in  thickness.  One  edge  is  provided  with  a  flange  containing  eyelets 
by  means  of  which  it  may  be  attached  to  the  inner  surface  of  a  suitable 
belt.  The  pad  should  rest  directly  upon  the  abdominal  surface,  so  that  its 
upper  border  is  slightly  above  the  level  of  the  umbilicus.  A  rubber  inlet 
tube  permits  the  introduction  of  air  for  inflation  of  the  pad. 

Puncture. 

This  operation  for  the  removal  of  accumulated  renal  fluids  is  best  per- 
formed with  an  aspirator,  figure  371,  although  trocars,  figures  377  to  381, 
are  sometimes  employed. 

526 


SURGERY    OF    THE    KIDNEYS.  527 

Nephropexy,  Nephrotomy,  Nephro-Lithotomy  and  Nephrectomy. 

As  the  instruments  required  for  nephropexy  (or  nephrorraphy)  neph- 
rotomy,  nephro-lithotomy  and  nephrectomy,  are  practically  the  same, 
whether  the  incision  be  extra-peritoneal  or  abdominal,  and  as  all  these 
operations  require  practically  the  same  list  of  appliances,  we  will  embrace 
all  under  one  head,  which  will  include  the  following: 

Minor  operating  list  on  pages  270  to  275. 

Scissors,  short  and  angular  for  enlarging  abdominal  incision,  figures 
925  and  926. 

Retractors  for  enlarging  field  of  vision,  figures  930  to  934. 

Flat  sponges  for  protecting  viscera,  absorbing  fluids,  etc.,  figures  686 
and  689. 

Long  compression  forceps  for  deep  hemostasia,  figures  938  to  944. 

Volsellum  forceps  for  manipulation  of  kidney,  figures  1025  to  1027. 

Tenacula  or  tenaculum  forceps  for  manipulation  of  flaps,  etc.,  figures 
950  and  1024. 

Long  tissue  forceps  for  holding  parts  for  excision  or  dissection,  figures 
947  to  949. 

Transfixion  needles  for  passing  ligatures,  figure  1109. 

Needles  for  suturing  external  opening,  figures  957  to  960. 

Drainage  tubes,  figures  961  to  966. 

Sutures,  silkworm  gut,  catgut  or  silk,  figures  708  to  728. 

Supporting  bandage  to  be  worn  after  operation. 
And  a  selection  from  among  the  following : 
If  for  a  lumbar  incision, 

Pad  or  support  to  place  under  the  patient  to  raise  the  ilio-costal  region, 
figures  202  and  203. 
If  for  nephropexy, 

Special  needles  for  stitching  kidney  to  abdominal  wall. 

Absorbable  sutures  of  catgut  or  kangaroo  tendon,  figures  708  to  716. 
If  for  nephro-lithotomy, 

Renal  sound  used  in  searching  for  calculi. 

Renal  exploring  needle  for  ascertaining  condition  of  renal  substance. 

Renal  exploring  bougie  used  in  searching  for  calculi. 

Renal  lance  for  detaching  embedded  calculi. 

Renal  calculus  forceps  for  crushing  and  removing  calculi. 

Renal  scoop. 
If  for  nephrectomy, 

Ecraseur  for  temporary  circular  constriction  of  pedicle. 

Pads  or  Supports. 

Tthese  may  form  permanent  pieces  of  operating-room  furniture  or  be 
improvised  by  the  close  folding  of  any  firm  fabric.  The  appliances  illus- 
trated by  figures  202  and  203  are  admirably  adapted  for  this  purpose. 
The  height  must  vary  with  the  size  and  corpulency  of  the  patient,  usually 
from  3  to  5  inches  being  sufficient. 

Nephropexy  Needles. 

Needles  selected  for  stitching  the  kidney  to  the  posterior  abdominal 
wall  usually  have  non-cutting  edges.  Rounded  wire  needles  similar  to 
Emmet's,  figure  953,  are  sometimes  employed.  Greig  Smith  recommended 


GENITOURINARY    SURGERY. 


a  helical  needle,   as  is  shown  in  figure  1237. 
scription  are  shown  by  figures  1147  to  1151. 


Further  patterns  of  this  de- 


Figure  1237.    Helical  Needle. 

The  Helical  Needle,  shown  by  figure  1237,  is  spiral  in  form  and  has  an 
eye  in  the  point.  It  has  no  sharp  edges  and  with  the  handle  is  about  8 
inches  in  length. 

Supporting  Bandages. 

These  may  be  worn  by  the  patient  for  from  three  to  five  months  after 
operation.  Some  operators  prefer  those  of  elastic  material  as  exhib- 
ited in  figure  800,  so  that  a  continuous  pressure  may  be  exerted.  Many 
are  provided  with  a  pad,  so  that  increased  pressure  over  the  diseased  organ 
may  be  maintained. 


Figure  1238.     Kidney  Supporting  Bandage. 


The  Kidney  Supporting  Bandage  exhibited  by  figure  1238  consists  of 
an  ordinary  elastic  bandage.  They  may  be  procured  with  or  without  a  pad. 
Usually  they  are  about  4  inches  in  width  and  so  adjusted  that  they  will 
exert  an  even  and  uniform  pressure.  A  pad  similar  to  that  shown  in  figure 
2199  will  be  found  satisfactory. 

Ecraseurs  or  Constrictors. 

These  are  intended  for  temporary  use  and  are  similar  to  those  employed 
in  abdominal  hysterectomy,  as  described  on  page  496.  They  may  be  used 
to*  advantage  in  nephrectomy  for  securing  the  pedicle,  while  the  artery 
and  vein  are  being  permanently  ligated  and  severed. 


Figure  1239.    Tail's  Rope  Ecraseur. 

Tait's  Rope  Ecraseur,  as  traced  in  figure  1239,  is  probably  the  best  for 
this  purpose.     Its  use  insures  safety  during  an  operation,    either  where 


SURGERY    OF    THE    KIDNEYS. 


529 


it  is  difficult  to  separate  the  pedicle,  or  where  it  is  necessary  to  remove  a  very 
large   kidney  by   morcellement   through   a  lumbar  incision. 

Renal   Sounds. 

These  are  employed  in  searching  for  stone  in  the  interior  or  pelvis  of 
the  kidney. 


Figure  1240.    Renal  Sound. 

The  Renal  Sound,  as  shown  by  figure  1240,  is  a  small  and  short  instru- 
ment similar  to  that  employed  in  making  examinations  of  the  bladder  in 
children.  Usually  they  are  about  3  millimeters  in  diameter,  with  a 
straight  shaft  about  7  inches  in  length,  terminating  in  a  sharply  curved 
beak  about  5/3  of  an  inch  in  length. 

Renal  Exploring  Needles. 

Renal  Exploring  Needles  are  recommended  by  English  authorities  for 
locating  renal  calculi.  They  consist  of  sharply  pointed  needles  about  two  or 
three  inches  in  length  and  provided  with  handles.  Longer  ones  are  sel- 
dom employed,  for  there  is  danger  that  the  needle  point,  after  being 
pushed  through  the  cortex,  may  wound  the  large  renal  vessels. 


Renal  Bougies. 

These  are  also  employed  in  searching   for  stone, 
elastic  and  similar  to  those  used  in  the  male  urethra. 


They  are  usually 


Figure  1241.    Renal  Elastic  Exploring  Bougie. 

Renal  Elastic  Bougies  of  suitable  size  and  material  may  be  selected  from 
among  the  smaller  sizes  of  urethral  instruments.  The  one  shown  by  figure 
1241  should  be  of  silk,  woven  from  fine  material  and  of  high  finish. 

Renal  Lances. 

These  are  employed  for  tearing  away  the  tissues  surrounding  an 
impacted  stone.  A  lance  forceps,  also  recommended  for  this  purpose,  is 
sometimes  employed. 

Renal  Calculus  Forceps. 

Forceps  are  required  for  dislodging  and  breaking  up  exposed  calculi. 
In  general  form  they  usually  resemble  those  used  for  removing  polypi  from 
the  nares. 


Figure  1242.    Kelly's  Renal  Calculus  Forceps. 


34 


530  GENITOURINARY    SURGERY. 

Kelly's  Renal  Calculus  Forceps,  as  shown  in  figure  1242,  are  provided  with 
shanks  nearly  straight,  with  handles  slightly  curved  downward  and  with 
jaws  curved  upward  on  the  flat.  The  latter  are  short,  strong,  fenestrated 
and  have  lateral  serrated  margins,  thus  furnishing  a  good  grasping  surface. 

Renal  Scoops. 

These  consist  of  spoon-shaped  instruments  used  to  dislodge  and  remove 
small  stones  or  pieces  of  stones  from  the  pelvis  of  the  kidney. 


Figure  1243.    Renal  Scoop. 

Renal  Scoops,  as  shown  by  figure  1243,  consist  of  handle,  shank  and  bowl. 
The  latter  is  usually  about  %  of  an  inch  in  diameter,  while  the  whole 
instrument  is  about  8  inches  in  length. 


SURGERY  OP  THE  BLADDER. 

The  mechanical  appliances  employed  in  surgical  interference  with  the 
bladder  may  be  divided  into  those  used  for  examination,  retention  of  urine, 
incontinence  of  urine,  exstrophy,  removal  of  foreign  bodies,  flushing  or 
washing  out,  applications,  litholapaxy,  and  cystotomy. 

Examination  of  the  Bladder. 

A  diagnosis  of  the  physical  condition  of  the  interior  of  the  bladder  may 
involve  the  use  of — 

Catheters  for  withdrawal  of  urine. 

Cystoscopes  for  illumination  and  ocular  observation. 

Sounds  for  the  detection  of  stone. 

Catheters. 

These  will  be  fully  described  in  a  section  of  this  chapter  devoted  to 
appliances  for  use  in  urine  retention. 

Oystoscopes. 

These  are  instruments  used  for  ocular  examination  of  the  interior  of  the 
urinary  bladder. 

The  first  apparatus  devised  for  illuminating  the  male  bladder  consisted 
of  a  long  endoscopic  tube  and  an  external  reflector.  These  combinations, 
although  used  for  vesical  examinations,  were  often  called  urethroscopes. 

Nitze  improved  upon  this  plan  by  not  only  introducing  an  electric  light 
into  the  vesical  cavity  and  thus  illuminating  its  entire  wall,  but  by  arrang- 
ing a  system  of  prisms  and  lenses  by  means  of  which  larger  areas  of  surface 
could  be  brought  in  to  view. 

The  Electrical  Cystoscope  consists  of  a  metallic  tube  usually  from 
No.  22  to  No.  29  French  scale,  and  from  8  to  16  inches  in  length,  the 
distal  end  of  which  is  bent  at  an  angle  forming  what  is  commonly  known 
as  a  beak.  An  electric  lamp,  connecting  with  an  insulated  wire  within  the 
instrument,  is  located  in  the  distal  end  of  this  beak,  and  is  covered  with 
a  pane  of  pebble  or  transparent  rock  crystal  that,  by  its  property  as  a  non- 
conductor, prevents  burning  of  the  bladder  wall. 


CYSTOSCOPES. 


531 


In  or  near  the  angle  of  the  curve  a  window  is  provided,  through  which 
the  light  passes  directly  upon  the  hypothenuse  of  a  right-angled  prism,  by 
which  the  rays  are  conducted  directly  to  the  eye  of  the  observer  Lenses  in 
the  eye-piece  correct  the  focus  and  magnify  the  image  until  a  space  about 
1 i£  inches  in  diameter  may  be  observed  at  one  time  without  moving  the 
instrument.  Two  patterns  are  in  common  use,  one  of  which  has  the  lamp 


Nitze's  Number  1  Cystoscope. 


Figure  1245.    Nitze  s  Number  2  Cystoscope 


Figure  1246.    Nitze's  Number  3  Cystoscope. 


in  the  convexity,  the  other  in  the  concavity  of  the  curvature,  the  latter 
being  generally  preferred  in  cases  where  the  operator  has  only  one. 

Many  of  these  instruments  are  constructed  with  inlet  and  outlet  channels, 
so  that  a  current  of  cold  water  may  be  passed  through  the  shaft,  thus  pre- 


Figure  1247.    Letter's  Cystoscope. 

venting  the  apparatus  from  becoming  heated  by  the  action  of  the  partially 
arrested  electric  force.  The  lamps  should  be  so  constructed  as  to  be  easily 
removed  and  when  necessary  replaced. 

They  are  manufactured  in  various  sizes,  usually  the  largest  one  admis- 
sible in  any  given  case  being  selected.  By  means  of  them,  calculi  that  have 
escaped  all  other  means  of  diagnosis  may  frequently  be  discovered.  It 


532 


GENITOURINARY    SURGERY. 


should  be  remembered  that  as  oil  forms  an  opaque  covering  over  a  glass 
lens,  it  should  not  be  employed  as  a  lubricant.  Glycerine,  which  is  trans- 
parent, is  best  adapted  for  this  use. 

Nitze's  Cystoscopes,  as  pictured  in  figures  1244,  1245  and  1246,  do  not  differ 
from  the  general  description  before  given.  Nos.  i  and  3  differ  in  that 
the  light  from  the  former  is  on  the  inside  of  the  curve,  while  that  in  No. 
2  is  on  the  outside.  No.  3,  with  the  light  on  the  inside  of  the  curve, 
contains  in  addition  to  the  light-conducting  tube,  a  double-channel  catheter, 
by  means  of  which  a  flow  of  water  may  be  maintained  through  the  instru- 
ment and  bladder. 

Letter's  Cystoscopes,  as  exhibited  in  figure  1247,  not  only  possesses  all  the 
advantages  of  the  patterns  of  Nitze  previously  described,  but  contains  in 
addition  a  channel  for  the  introduction  of  slender  instruments  for  operating 
purposes.  These  instruments  may  consist  of  metal  catheters,  applicators, 
knives  of  various  forms,  etc. ,  any  of  which  may  be  obtained  with  the  instru- 
ment. Means  are  provided  for  irrigation  that  by  a  continuous  flow  of  water 
the  instrument  may  be  prevented  from  becoming  heated. 


Figure  1248.    Casper's  Cystoscope. 

Casper's  Cystoscope,  as  portrayed  by  figure  1248,  is  said  to  be  an  improve- 
ment on  the  older  patterns  of  Leiter  and  Nitze.  In  general  form  it  differs 
materially  from  the  models  before  constructed.  Instead  of  the  angular-bent 
beak,  the  tip  is  only  slightly  curved  on  the  edge.  The  returning  beam  of 
light  in  passing  through  the  instrument  by  the  aid  of  prisms  and  mirrors, 


Figure  1249.    Dittel's  Bladder  Phantom. 

turns  two  right  angles,  so  that  it  is  delivered  to  the  eye  of  the  operator  on  a 
line  parallel  with  the  long  axis  of  the  instrument,  but  out  of  the  direct  line 
of  vision.  While  it  is  constructed  without  means  of  irrigation,  it  possesses 
the  advantage  that  it  is  supplied  with  a  catheter  through  which  an  elastic 


SOUNDS.  533 

ureteral  catheter  may  be  introduced  and  catheterization  of  the  male  ureters 
successfully  accomplished  without  the  aid  of  other  instruments.  The 
apparatus  may  be  used  as  an  ordinary  catheter  or  the  catheter  slot  may  be 
filled  with  a  solid  staff,  thus  preventing  the  escape  of  urine  through  the 
instrument.  The  tube  is  oval  in  form,  9^  inches  in  length,  about  8  milli- 
meters in  its  long  and  5  millimeters  in  its  short  diameter.  Two  elastic  web 
ureteral  catheters  about  30  inches  in  length  accompany  the  instrument. 

Dittel's  Bladder  Phantom,  as  manifested  by  figure  1249,  is  an  imitation 
of  the  natural  organ.  It  consists  of  a  globe  divided  in  halves  by  a  hinged 
water-tight  joint,  the  inner  surface  of  which  is  painted  so  as  to  show  the 
location  of  the  ureters  and  vessels  and  other  land  marks  of  importance  in 
diagnosis.  A  short  tube  somewhat  larger  than  the  normal  urethra  when 
distended,  is  attached  to  the  lower  border  of  the  globe  in  such  a  manner 
that  a  cystoscope  may  be  introduced,  while  the  former  is  filled  with  water. 
This  appliance  will  be  found  valuable  both  in  studying  and  teaching  the 
use  of  the  electric  cystoscope. 

Vesical  Sounds, 

Sounds  for  the  diagnosis  of  vesical  calculi  in  the  male,  are  slender  metal- 
lic instruments  with  curved  tips  and  of  a  size  that  may  be  passed  through 
the  normal  urethra  without  previous  dilatation.  If  the  shaft  be  of  small 
size,  it  may  also  be  moved  freely  in  the  urethra.  Two  styles  of  handles  are 
in  use,  a  corrugated  cylinder  and  a  flattened  discoid  form,  similar  to  those 
of  the  ordinary  urethral  sound.  The  former  are  preferred  for  systematic 
rotation,  and  are  usually  seen  in  the  hollow  varieties.  Solid  sounds  usually 
have  a  flattened  handle,  one  side  of  which  (generally  that  toward  which 
the  beak  is  curved)  is  corrugated  or  otherwise  plainly  marked  that  the 
direction  of  the  curve  may  at  all  times  be  known.  The  general  form  is 
usually  that  of  a  straight  shaft,  terminating  in  a  curved  tip  or  beak,  slightly 
bulbous  or  enlarged  at  the  end.  They  are  constructed  both  solid  and  hol- 
low. The  size  for  an  adult  is  about  4%  millimeters  in  diameter. 

Two  instruments  should  always  be  in  readiness,  one  with  a  slight  curve 
like  that  of  an  ordinary  male  urethral  sound,  the  other  more  sharply  bent 
and  with  a  shorter  beak,  that  the  space  immediately  behind  the  prostate 
may  be  also  included  in  the  examination.  The  contact  of  the  point  of  the 
sound  with  a  calctilus  is  accompanied  by  a  metallic  click,  easily  recognized 
by  the  experienced  ear.  These  metallic  clicks  vary  with  the  nature,  size 
and  surroundings  of  the  stone  and  the  character  of  metal  from  which  the 
sound  is  constructed,  a  harder  material,  like  steel,  giving  much  rapid  and 
accurate  evidence  than  a  softer  one. 

Sounding  is  advised  in  all  cases  of  cystotomy  for  stone  just  previous  to 
the  first  incision  and  immediately  following  the  closing  of  the  bladder  open- 
ing, at  first,  to  verify  beyond  question  the  existence  of  a  calculus  at  the 


Figure  1250.    Plain  Steel  Calculus  Sound. 

moment  of  operating,  and  finally  to  determine  if  all  of  the  calcareous  depos- 
its have  been  removed.  Sounds  should  be  well  oiled  and  warmed  before 
introduction,  and  the  sounding  should  be  conducted  with  the  bladder  par- 
tially filled  with  fluid,  as  otherwise  encysted  stones  may  escape  detection. 
The  Plain  Steel  Calculus  Sound,  as  portrayed  by  figure  1250,  consists 
of  a  metallic  shaft,  about  10  inches  in  length,  slightly  conical,  excepting 


534  GENITOURINARY    SURGERY. 

at  the  tip  where  it  is  enlarged  into  a  bulb-shaped  point.     They  may  be  pro- 
cured with  shafts  of  almost  any  size,  ranging  from  6  to  12  American  scale. 


Figure  1251.    Goulay's  Vesical  Sound  for  Calculus. 

Goulay's  Vesical  Sound  for  Calculcus  has  a  handle  and  shaft  of  the  ordi- 
nary pattern.  As  traced  in  figure  1251,  the  tip  is  flattened  and  sharply 
curved  on  the  flat.  This  curve  embraces  a  trifle  more  than  a  quarter  of  an 
arc.  It  is  well  adapted  for  sounding  the  dependent  portion  of  the  bladder, 
particularly  when  there  is  a  bulging  of  the  prostate. 


Figure  1252.    Thompson's  Calculus  Sound. 

Thompson's  Calculus  Sound,  as  pictured  in  figure  1252,  consists  of  a 
hollow  shaft  with  a  bulbous  distal  tip,  the  proximal  end  terminating  in  an 
enlargement  or  handle,  and  supplied  with  a  stopper,  by  means  of  which  any 
fluid  in  the  bladder  may  be  there  retained  until  its  withdrawal  is  advised. 

One  advantage  claimed  for  this  pattern  is  that  by  it  the  antero-posterior 
breadth  of  a  discovered  calculus  may  be  more  closely  determined.  The 
shaft  is  graduated  and  supplied  with  a  sliding  ring.  By  passing  the  beak  of 
the  instrument  to  the  extreme  or  inner  border  of  the  stone  and  sliding  the 
ring  forward  until  it  rests  against  the  external  meatus  and  then  tapping 
lightly  along  the  surface  of  the  stone  until  the  outer  or  nearer  border  is 
located,  the  distance  between  the  ring  and  the  then  point  of  contact  with 
the  meatus,  will  designate  the  diameter  of  the  stone  in  question.  This  in- 
strument acts  as  a  catheter  by  which  fluid  may  be  injected  or  withdrawn 
from  the  bladder  during  the  process  of  sounding. 


Figure  1253.    Andrews'  Calculus  Sound. 

Andrews'  Calculus  Sound,  as  displayed  by  figure  1253,  consists  of  a 
catheter-like  metallic  tube,  to  which  an  ear-tip  is  attached  by  means  of  a 
rubber  hose.  It  is  claimed  by  its  inventor  that  it  is  an  advantage  to  con- 
nect the  ear  directly  with  the  sound  in  the  manner  described.  Lateral 
wings  near  the  proximal  end  of  the  catheter  facilitate  manipulation. 

Retention  of  Urine. 

The  bladder  may  be  relieved  of  retained  urine  by  the  application  of 
heat,  catheterism  and  puncture. 

Application  of  Heat. 
The  application  of  heat  may  be  by   sitz  baths,  cloths,  rubber  bags  or 


CATHETERS.  535 

rectal  injections,  according  to  methods  fully  described  in  a  chapter  devoted 
to  the  Resolution  of  Inflammation,  figures  401  to  410. 

Catheterism. 

This  consists  in  the  introduction  into  the  bladder  of  certain  forms  of 
tubes,  called  catheters,  which  serve  as  artificial  non-closing  channels,  for 
the  escape  and  conduct  of  the  urine.  Generally  speaking,  catheters  consist 
of  tubes  for  evacuating  or  injecting  fluids  through  a  natural  passage. 

The  invention  of  catheters  antedates  the  Christian  era.  This  is  proved 
not  only  by  the  literature,  but  metal  catheters  have  been  found  amidst 
ruins  of  great  antiquity. 

These  earlier  instruments  differ  little  from  the  patterns  in  use  to-day. 
Generally  they  were  of  metal,  although  we  learn  that  the  stems  of  certain 
plants  and  other  elastic  materials  were  occasionally  employed.  Efforts  were 
made  in  the  i6th.  century  to  produce  satisfactory  elastic  instruments. 
Strips  of  linen,  spirally  wound  and  covered  with  wax,  leather  and  various 
other  materials  were  used  with  more  or  less  success.  The  first  really  serv- 
iceable elastic  catheters  were  made  by  weaving  silk  threads  over  an  inner 
spiral  wire  frame,  covering  the  whole  with  varnish  or  lacs  or  various  com- 
positions. Strangely  enough,  this  method  was  revived  a  few  years  ago, 
and  catheters,  claimed  to  be  manufactured  on  a  new  principle,  were  placed 
upon  the  market.  After  some  years  of  experience  with  the  early  patterns, 
the  inner  wires  were  abandoned  and  the  woven  fabric  catheter  became  a 
standard  instrument.  Since  the  introduction  of  soft  rubber  it  has  been 
extensively  employed.  This  material  with  the  various  forms  of  woven  fab- 
rics are  now  used  almost  to  the  exclusion  of  metallic  instruments. 

There  are  two  classes  of  catheters,  elastic  and  rigid. 

Elastic  Catheters  not  only  afford  the  advantage  of  a  yielding  instrument 
that  will  follow  various  curvatures,  but  they  are  constructed  with  many 
forms  of  tips,  thus  meeting  the  requirements  of  various  cases.  Elastic 
catheters  are  made  of  web,  soft  rubber  and  spiral  metal. 

Elastic  Web  Catheters.  When  properly  manufactured,  this  class  of  in- 
struments is  more  satisfactory  than  those  made  from  other  material.  They 
are  almost  indispensable  to  patients  who  are  obliged  to  use  them  regularly. 
Soft  rubber  catheters  are  not  only  far  from  serviceable,  but  they  lack  the 
necessary  resistance,  and  in  addition  they  are  liable  to  become  brittle  when 
old,  and  break  when  in  use. 

Elastic  web  catheters  are  woven  tubes,  knitted  in  the  same  manner  as 
the  covering  of  a  horsewhip.  Usually  the  mandril  is  stationary,  while  the 
spools,  which  carry  the  threads,  several  in  number,  are  motmted  on  one  or 
more  revolving  cylinders  in  such  a  manner  that  one-half,  or  every  other 
one  of  the  spools,  travels  in  one  direction,  the  balance  in  an  opposite  way, 
while  they  pass  each  other  in  and  out  exactly  as  do  the  dancers  in  a  "grand 
right  and  left"  figure.  The  size  and  shape  of  the  catheter  depend  on  the 
form  and  size  of  the  mandril  over  which  it  is  woven.  In  their  manufacture 
any  quality  or  number  of  threads  desired  may  be  used. 

Some  makers  have  placed  on  the  market  what  they  call  double-wall 
catheters,  or  those  in  which  two  thicknesses  of  woven  fabric  are  knitted  one 
over  the  other  on  a  mandril.  These,  in  our  opinion,  possess  no  special  ad- 
vantage in  the  way  of  durability.  On  the  other  hand,  the  catheter  loses 
something  of  its  soft  elastic  quality,  and  is,  hence,  more  liable  to  crack  when 
sharply  curved. 

As  all  catheters  of  this  class  are  heavily  coated  with  successive  coverings 


536  GENITO-URINARY     SURGERY. 

of  copal  varnish,  shellacs,  lacquers  or  similar  substances,  imperfections  in 
manufacture  are  easily  concealed  by  unscrupulous  makers.  The  web  should 
be  of  fine,  firm  material,  closely  woven,  of  uniform  texture,  free  from  pro- 
truding ends,  irregularities  or  unevenly  covered  places.  Silk  furnishes  an 
ideal  fiber,  and  is  recommended  above  all  other  material.  It  possesses 
greater  strength,  more  elasticity,  and  owing  to  the  fineness  of  its  substance 
does  not  require  as  heavy  coatings  of  lacquer.  A  large  percentage  of  the 
so-called  silk  catheters  are  only  mixtures  of  cotton  and  silk,  and  hence  in 
reality  are  no  better  than,  and  hardly  equal  to,  pure  linen.  This  condition 
may  account  for  the  poor  satisfaction  sometimes  obtained  from  the  use  of 
catheters  supposed  to  be  made  from  pure  silk. 

The  manner  of  forming  the  eye  of  a  catheter  is  of  the  utmost  importance, 
because  most  catheters  break  or  crack  at  the  point  of  its  insertion.  As  a 
catheter  is  knitted  over  a  rod,  it  is  tubular  when  completed.  Formerly  there 
were  but  two  methods  for  constructing  the  necessary  eye :  either  cutting  or 
burning ;  both  employed  before  the  application  of  the  elastic  coats. 

The  first  method  consisted  in  cutting  out  a  small  oval  piece  with  a  short 
thin-bladed  knife.  The  burning  process  was  done  with  an  oval  point  of  the 
size  required.  The  cutting  process  would  seem  preferable,  because  it  does 
not  destroy  the  fiber  beyond  the  point  of  removal  as  does  the  heat  from  the 
iron,  but  it  is  evident  that  either  of  these  methods  destroys  the  strength  of 
the  catheter  in  proportion  to  the  number  of  threads  severed. 

A  plan  has  been  recently  devised  by  which  the  eyes  are  woven  in.  Cer- 
tain threads  are  detached  from  the  mass  and  braided  in  such  a  manner  as 
to  leave  an  oval  opening  of  the  proper  size,  thus  forming  an  eye,  after 
which  the  threads  are  returned  to  place  and  the  catheter  completed. 
This  method  forms  an  eye  that  will  not  ravel.  It  will  bear  much  more  use 
and  abuse  without  becoming  roughened  and  the  catheter  is  not  materially 
weakened  in  construction. 

The  forming  of  the  catheter  end  is  another  important  item,  and  one  in 
which  there  is  great  opportunity  for  deception.  If  the  catheter  is  cylindrical, 
the  threads  require  braiding  and  tying  by  hand  over  the  mandril  end  before 
the  latter  is  removed.  In  cheaper  grades  of  catheters  this  is  not  done,  the 
threads  being  cut  and  a  coating  of  gum  or  varnish  depended  upon  to  hold 
the  loose  ends  of  the  threads  together.  In  large  sized  catheters  some  manu- 
facturers cover  the  end  with  a  small  cap  of  cloth,  or  a  piece  of  catheter  tube, 
pressed  into  shape  and  hardened  with  varnish.  While  these  plans  furnish 
an  instrument  of  good  appearance,  they  are  not  safe,  and  are  of  little  serv- 
ice to  patients. 

Much  more  important  is  the  forming  of  the  tips  of  bulbous,  conical  and 
rat-tail  catheters.  In  the  construction  of  these  forms  there  is  a  still  greater 
chance  for  inferior  workmanship.  It  is  evident  that  in  the  bulbous-tipped 
catheters,  the  webbing  threads  should  continue  unbroken  along  the  neck 
space  and  over  the  bulb  ending,  where  they  should  be  properly  fastened. 
We  have  examined  catheters  of  this  variety  that  furnish  every  evidence  of 
having  been  made  with  the  bulb  separate,  and  the  latter  joined  to  the  cathe- 
ter body  by  tying.  In  others  the  braid  is  continued  of  the  same  size  as  the 
neck,  and  the  bulb  formed  by  winding  a  fibrous  mass  outside  of  the  web.  Of 
course  this  plan  is  easier  and  cheaper  than  dropping  part  of  the  threads, 
while  the  neck  is  being  woven  and  taking  them  up  again  to  cover  the  bulb, 
as  should  be  done.  While  an  instrument  produced  by  such  a  plan  might 
present  a  perfect  appearance,  it  would  be  unsatisfactory  and  even  dangerous 
to  use.  In  conical  and  rat-tail  catheters  threads  are  dropped  one  at  a  time 


CATHETERS.  537 

until  the  extreme  point  is  reached,  when  the  remaining  threads  are  care- 
fully fastened. 

Another  feature  that  should  not  be  overlooked  is  the  material  used  and 
manner  of  filling  that  portion  of  the  lumen  of  the  catheter  which  lies  between 
the  eye  and  the  tip.  This  portion  of  the  canal  if  left  open  can  not  be 
cleansed.  It  furnishes  a  receptacle  for  urine  and  other  fluids  that  soon  de- 
compose, and  not  only  infect  but  spoil  the  catheter.  All  instruments  of 
high  quality  have  this  space  carefully  filled,  until  the  instrument  presents 
a  solid  end  distal  to  the  eye  opening. 

The  proper  coating  of  the  catheter  is  as  important  as  its  weaving.  This 
covering  must  be  smooth,  elastic,  impervious  to  urine  and  as  far  as  pos- 
sible, capable  of  withstanding  methods  of  sterilization.  After  many  years 
of  study  and  experiment  every  requirement  except  the  latter  has  been  satis- 
factorily met.  This  hitherto  necessary  imperfection  has  now  been  nearly, 
if  not  quite,  overcome,  leaving  little  more  to  be  asked  for  in  the  way  of 
perfect  instruments. 

Some  authors  have  stated  that  black  woven  catheters  are  the  best,  be- 
cause they  are  more  elastic.  This  is  not  true.  The  color  of  the  catheter 
has  no  more  to  do  with  its  quality  than  the  coat  of  paint  on  the  out- 
side of  a  house  indicates  the  character  of  the  structure.  Varnish  can  be 
manufactured  of  any  color,  and  it  is  our  experience  that  black  is  generally 
employed  in  the  cheaper  grades  of  catheters  to  cover  up  poor  weaving  and 
inferior  material.  Many  of  the  finer  grades  of  catheters  are  so  light  in 
color  and  the  varnish  so  transparent  that  the  weaving,  both  as  to  quality  of 
material  and  workmanship,  may  be  examined  through  the  coating. 

One  feature  overlooked  by  purchasers  is  the  lack  of  coating  on  the  inside 
of  catheters.  To  be  serviceable  it  is  necessary  that  the  varnish  should 
cover  the  lumen  of  the  tube,  as  well  as  the  outside,  for  the  interior  is  brought 
into  contact  with  the  passing  urine,  every  drop  of  which  should  be  pre- 
vented from  becoming  absorbed  by  the  catheter  fiber. 

By  cutting  open  almost  any  of  the  common  forms  and  many  of  the  so- 
called  higher  grades  of  catheters,  the  lumen  will  be  found  poorly  if  at  all 
protected  from  this  source  of  infection.  Catheters  properly  coated  upon  the 
inside  can  easily  be  cleaned,  while  those  with  a  rough  inner  surface  afford 
protection  for  numerous  hosts  of  bacteria  difficult,  if  not  impossible,  to  dis- 
lodge or  destroy.  The  cleanliness  of  a  catheter  depends  largely  on  the  ex- 
tent and  quality  of  its  inner  covering. 

The  coating  of  catheters  must  not  only  be  water-proof,  but  elastic,  the 
latter  being  sufficient  to  admit  of  sharp  curves  in  the  instrument.  It  should 
be  remembered,  however,  that  the  elasticity  of  web  catheters  depends  on 
their  temperature,  many  catheters  returned  to  dealers  because  the  var- 
nish was  found  to  crack,  were  curved  while  cold.  It  is  essential  that  the 
curve  of  the  catheter  be  not  changed  until  it  has  been  sufficiently  warmed 
enough  to  become  soft  and  pliable. 

The  coating  of  a  good  catheter  requires  several  weeks  of  time  and  many 
covers  of  varnish.  Each  succeeding  coat  is  "rubbed  down"  with  pumice 
stone,  or  similar  material,  exactly  as  is  the  coating  of  a  fine  carriage.  To 
be  elastic,  slow  drying  varieties  of  varnish  are  used  and  the  warming  or 
baking  process  continued  for  long  periods. 

One  source  of  complaint  on  the  part  of  purchasers  may  be  traced  to  the 
jobber  or  retailer,  who  frequently  supplies  customers  with  catheters  and 
bougies  so  old  as  to  be  practically  worthless. 

A  catheter  to  be  serviceable  must  be  reasonably  new,  because  a  mixture 


538  GENITO-URINARY    SURGERY. 

of  woven  fiber  with  varnish  or  similar  gums,  undergoes  a  slow  process  of 
disintegration,  eventually  resulting  in  a  brittle  fibrous  mass,  unfit  for  use 
in  an  instrument  of  this  class. 

In  the  selection  of  catheters  those  only  should  be  chosen  that  will  permit 
of  sterilization,  either  by  steam,  formaldehyde  gas,  boiling  water  or  some 
other  process  positively  germicidal  in  its  effects.  Boiling  water  would  seem 
impracticable  and  yet  catheters  have  been  examined  by  the  writer  that  have 
withstood  successive  immersions  in  boiling  water  for  five  minutes  on  six 
separate  occasions  without  serious  injury  to  the  varnish  coating.  Any  first- 
class  catheter  of  linen  or  silk  may  be  subjected  to  steam  sterilization  for  20 
minutes,  while  formaldehyde  gas  will  not  affect  them  at  all,  unless  long 
continued. 

Disinfection  by  chemical  methods  is  of  little  value,  because  if  the  germi- 
cidal fluid  be  sufficiently  strong  to  penetrate  to  and  effectually  kill  all  forms 
of  bacteria,  it  will  also  serve  to  destroy  or  disintegrate  the  substance  of  the 
catheter  coating.  This  is  true  of  carbolic  acid,  corrosive  sublimate  and  all 
powerful  chemical  agencies  so  far  as  we  have  been  able  to  determine.  How 
destructive  the  effect  of  these  chemical  changes  is  to  these  coatings  can  be 
realized  only  by  cutting  open  a  much-used  catheter  that  has  been  frequently 
submitted  to  immersion  in  such  solutions.  Usually  the  inner  catheter  coat- 
ing will  be  found  to  be  soft  or  wholly  wanting,  and  the  fibers  exposed  to  the 
dried  action  of  both  the  sterilizing  fluid  and  the  urine ;  in  short,  a  good  cathe- 
ter is  ruined.  Schimmelbusch  claims  that  web  catheters  may  be  success- 
fully disinfected  by  briskly  rubbing  them  for  one  minute  with  a  wet  com- 
press or  towel  to  be  followed  by  energetic  rubbing  with  a  dry  sterile  cloth. 
For  the  latter  he  advises  the  use  of  a  freshly  laundered  towel.  As  these 
results  were  announced  after  a  series  of  laboratory  tests,  we  can  not  question 
the  method  when  as  carefully  applied  as  it  was  by  its  author.  This  method, 
however,  makes  no  provision  for  the  internal  sterilization  of  these  instru- 


Figure  1254.    Steam  Sterilizer  for  Catheters. 


ments.  Dennis  advises  for  this  purpose  a  small  portable  steam  boiler,  de- 
vised by  Von  Farkus  of  Buda  Pesth.  It  is  possible  that  with  both  of  these 
methods  perfect  sterilization  may  be  secured,  but  as  long  as  makers  can 
produce  high-class  catheters  that  can  be  boiled  without  injury  to  their  elastic 
coatings,  the  latter  should  be  employed. 


CATHETERS. 


539 


Catheter  Sterilization  may  be  secured  by  various  methods.  The  ap- 
paratus displayed  by  figure  1254  consists  of  a  steam  boiler,  heated  by 
means  of  an  ordinary  spirit  lamp.  The  generated  steam  finds  an  outlet 
through  a  curved  conical  pipe  of  such  size  that  it  may  be  attached  to. an 
elastic  web  or  soft  rubber  catheter.  A  stream  of  live  steam  may  thus  be 
forced  throughout  the  entire  catheter  length.  A  safety  valve  guards 
against  over-pressure. 

Formaldehyde  gas  seems  to  offer  an  ideal  method,  and  its  use  is  recom- 
mended. 

Elastic  catheters  should  be  stored  straight  without  curves.  This  is  not 
only  their  natural  condition,  but  on  removing  a  catheter  from  a  curved  re- 
ceptacle, it  is  natural  for  the  operator  to  at  once  straighten  it;  this,  as  first 
explained,  is  detrimental  to  the  catheter  coating. 

A  Catheter  Lubricant  is  a  necessity,  and  should  be  aseptic.  Belfield  ad- 
vises that  instead  of  the  oils  and  ointments  usually  employed,  a  5  per  cent 
solution  of  borax  in  glycerine  be  used. 

After  use,  all  oil  or  other  form  of  grease  should  be  carefully  removed 
from  elastic  web  catheters,  as  its  pressure  tends  to  soften  the  varnish  coats. 

Elastic  web  catheters  may  usually  be  procured  in  sizes  ranging  from 
No.  3  to  No.  15,  American  scale.  The  latter  is  the  method  of  numbering 
usually  adopted  in  this  country.  It  is  safer,  however,  in  ordering  to  desig- 
nate the  number  of  the  scale  used  in  measurement,  otherwise  the  order 
may  be  misinterpreted  by  the  dealer.  The  forms  common  in  use  are,  olive 
tip,  cylindrical,  conical,  prostatic,  Mercier  coudee,  Mercier  bicoudee  and 
rat-tail. 

Olive-Tip  Catheters  are  constructed  with  an  olive-shaped  extremity,  sur- 
mounting a  slender  neck-like  shank.  In  a  flexible  instrument  this  form  of 
tip  is  well  adapted  to  follow  a  tortuous  canal.  This  pattern,  although  a 
trifle  more  expensive  than  the  cylindrical,  is  now  extensively  used. 


Figure  1255.    Olive  Tip  Elastic  Web  Catheter. 

The  Olive-Tip  Elastic  Web  Catheter,  as  displayed  by  figure  1255,  may 
be  usually  obtained  in  silk,  linen  and  cotton.  Unless  reliable  dealers  are 
patronized,  the  buyer  will  often  receive  cotton  or  an  admixture  of  it,  no 
matter  what  price  is  paid.  The  better  grades  are  manufactured  from  silk 
and  linen,  and  are  preferable.  Owing  to  the  general  sale  of  this  pattern 
it  is  usually  carried  in  stock  in  larger  and  smaller  sizes  than  other  varieties, 
and  the  surgeon  who  fails  to  procure  what  might  be  termed  "odd  sizes"  in 
other  models,  may  easily  secure  them  in  this  form. 

Cylindrical  Catheters  consist  of  plain  tubes,  with  closed  ends,  which  are 
either  straight  or  curved. 


Figure  1256.    Cylindrical  Elastic  Web  Catheters. 

The  Cylindrical  Elastic  Web  Catheter,  as  shown  by  figure  1256,  illus- 
trates the  ordinary  old-fashioned  pattern.  In  the  cheaper  grades,  like  the 
commercial  English  catheter,  the  body  is  of  coarse  cotton,  and  the'covering 
of  cheap  shellac.  Usually  these  are  curved,  each  being  supplied  with  a  wire 
stylet.  The  latter  are  used  to  stiffen  the  catheter  when  necessary,  and  in 
certain  cases  to  keep  the  channel  open.  The  curve  of  the  stiff  varieties  may 
be  changed  by  placing  them  in  hot  water,  curving  them  while  warm  and 


GENITO-URINARY    SURGERY. 


holding  them  in  the  desired  shape  until  cold.     They  may,  however,  be  ob- 
tained in  better  qualities,  including  both  linen  and  silk. 

Conical  Catheters  gradually  decrease  in  size  near  the  tip  until  they  termi- 
nate in  a  fine  point. 


Figure  1357.    Conical  Elastic  Web  Catheter. 

The  Conical  Elastic  Web  Catheter,  as  indicated  by  figure  1257,  presents 
a  gradually  decreasing  diameter.  It  is  claimed  that  in  certain  cases  they 
are  more  easily  introduced  than  other  forms.  They  may  be  procured  in 
either  linen  or  silk  and  of  the  usual  numbers. 

Prostatic  Catheters  differ  from  other  patterns  in  being  longer  and  cur- 
ved upon  a  larger  circle  than  that  represented  by  a  normal  urethra.  The 
object  of  the  long  curve  is  to  enable  the  instrument  to  more  easily  pass  the 
membranous  folds  that  project  into  the  canal  in  such  a  manner  as  to  form  a 
sac-like  space  in  many  cases  of  prostatic  enlargement.  By  means  of  the 
large  curve  previously  referred  to,  projection  is  obtained  in  a  direction  that 
will  often  pass  these  obstructions. 


Mercier's  Single  Elbow  (Coudee) 
Catheter. 


Mercier's  Double  Elbow  (Bicoudee)  Catheter. 


Figure  1260.    Prostatic  Web  Catheter. 

Prostatic  Elastic  Web  Catheters,  as  set  forth  in  figure  1260,  are  for  use 
in  cases  where  the  canal  is  somewhat  elongated,  and  should  therefore  be  at 
least  1 6  inches  in  length.  Although  they  are  manufactured  from  silk, 
linen  and  cotton,  owing  to  their  limited  sale  they  can  not  usually  be  ob- 
tained excepting  in  linen  and  cotton,  and  then  only  in  the  more  common 
sizes. 

Mercier's  Coudee  Catheters,  as  depicted  in  figures  1258  and  1259, 
differ  from  the  cylindrical  forms  only  in  having  angular  curves  near  the 
points.  The  eye  in  these  instruments  is  between  the  tip  and  the  bend, 
and  this  usually  is  about  ^  of  an  inch  from  the  extreme  end.  They  are 
used  in  cases  of  enlarged  prostate,  it  being  claimed  that  they  will  better 
follow  the  curvature,  for  the  reason  that  the  bent  tip  will  pass  anteriorly 
over  the  enlargement. 


CATHETERS.  541 

Mercier's  Coudee  Elastic  Web  Catheters,  as  appear  in  figure  1258,  are 
a  somewhat  popular  form  of  catheter,  and  may  be  purchased  in  a  great 
variety  of  qualities.  Unfortunately,  a  large  percentage  of  those  on  the 
market  are  of  cheap  foreign  make,  many  being  almost  unfit  for  use.  Only 
pure  linen  or  silk  instruments  of  the  best  finish  should  be  used. 

Mercier's  Bicoudee  Elastic  Web  Catheters,  as  is  shown  by  figure  1259, 
differ  from  those  last  mentioned  only  in  being  provided  with  a  second 
bend,  located  about  2  inches  from  the  distal  end.  The  bend  is  in  the  same 
direction  as  that  at  the  tip. 

Rat  Tail  Catheters  are  constructed  with  a  long  slender  soft  elastic  tip, 
which  usually  projects  5  or  6  inches  from  the  eye.  They  form  a  combina- 
tion of  a  filiform  bougie  and  a  catheter.  It  is  claimed  that  they  can  be 
advantageously  used  in  many  cases  of  prostatic  enlargement. 


Figure  1261.    Rat  Tail  Elastic.  Web  Catheter. 

Rat  Tail  Elastic  Web  Catheters,  as  illustrated  by  figure  1261,  are 
usually  either  constructed  of  silk  or  linen.  As  the  demand  for  them  is  not 
great,  they  can  be  secured  only  in  medium  sizes. 

Soft  Rubber  Catheters  are  pieces  of  soft  rubber  tubing  closed  at  one 
end,  a  lateral  opening  or  eye  being  provided  near  the  tip.  Owing  to  their 
softness  and  the  slight  danger  of  injuring  the  lining  of  the  urethra,  these 
catheters  have  been  extensively  used.  They  serve  an  admirable  purpose 
in  the  normal  urethra,  but,  owing  to  their  extreme  softness,  they  are  not 
adapted  for  passing  through  strictures.  Unfortunately,  soft  rubber  dete- 
riorates with  age.  The  variety  best  adapted  for  catheters,  usually  known 
as  red  or  vermilion  rubber,  although  of  fine  quality,  soon  becomes  stiff 
and  brittle.  It  is  a  singular  fact  that  if  soft  rubber  catheters  are  used 
occasionally  they  will  last  much  longer  than  if  allowed  to  remain  idle.  As 
many  accidents  have  occurred  by  the  breaking  of  soft  rubber  catheters 
while  in  situ,  it  is  advised  that  such  catheters  be  not  introduced  until  their 
elasticity  has  first  been  determined.  This  may  be  ascertained  by  grasping 
the  instrument  at  both  ends  and  stretching  it  longitudinally  or  bending  it 
sharply  upon  itself,  carefully  noting  whether  the  rubber  has  a  tendency  to 
break  or  crack  upon  the  outside  of  the  curvature.  Unless  they  are  found 
soft  and  elastic  they  should  not  be  used. 

The  smoother  and  better  grades  are  formed  in  glass  moulds,  each  pro- 
ducing a  catheter  of  a  given  size.  Instruments  made  on  this  plan  present 
a  soft  and  glossy  appearance  and  an  almost  perfect  surface  for  contact  with 
the  mucous  membrane.  The  low  price  at  which  these  goods  are  frequently 
sold  to  dealers  has  resulted  in  a  competition  among  makers  that  has  induced 
some  of  them  to  place  goods  on  the  market  which  are  of  such  poor  quality 
as  to  be  practically  worthless.  Such  catheters  are  soft,  flimsy,  with  thin 
walls  and  of  short  lengths. 

All  soft  rubber  of  good  quality  will  absorb  oils  and  fats.  As  it  is  neces- 
sary to  lubricate  catheters  for  introduction,  those  of  soft  rubber  soon  become 
permeated  with  the  lubricant  until  they  swell  sometimes  to  nearly  twice 
their  size,  in  which  condition  they  are  soft,  spongy  and  practically 
worthless. 

The  eyes  of  soft  rubber  catheters  are  made  in  various  ways.  Plain  cut- 
ting with  knife  or  scissors  was  the  method  in  use  for  many  years.  Later 
these  cut  edges  were  seared  by  heat,  producing  a  fairly  soft  and  smooth 


542  GENITOURINARY    SURGERY. 

edge.  Now  nearly  all  of  the  eyes  are  moulded  and  present  a  soft  and 
smooth  appearance. 

Soft  rubber,  like  elastic  catheters,  are  manufactured  with  various 
shaped  tips;  there  is,  however,  practically  no  demand  for  any  excepting 
the  ordinary  cylindrical  patterns. 

Soft  rubber  catheters  should  be  stored  in  straight  boxes,  but  may  be 
coiled  when  necessary  for  transportation.  It  is  well  that  the  curve  be  not 
too  short.  A  pear-shaped  pocket  of  firm  cloth,  5  inches  in  diameter  at 
widest  portion,  3  inches  at  mouth  and  about  8  inches  in  length  is  recom- 
mended by  Chamberlain.  One  or  two  catheters  may  be  placed  in  this  case 
and  safely  carried  in  a  side  pocket.  Round  boxes  are  much  in  use. 
These  are  safe,  provided  the  catheters  are  removed'  occasionally,  stretched 
and  otherwise  manipulated  and  returned  to  the  box  curved  in  an  opposite 
direction. 


Figure  1262.    Soft  Rubber  Elastic  Catheter. 

Soft  Rubber  Catheters,  as  shown  by  figure  1262,  are  manufactured  with 
moulded  eyes.  When  of  good  quality,  the  walls  are  of  fair  thickness,  that 
they  may  offer  the  desired  amount  of  resistance  in  passing  an  obstruction. 
They  may  be  obtained  in  sizes  varying  from  No.  5  to  20,  American  scale. 

Catheter  Guides  may  be  used  to  strengthen  soft  rubber  catheters,  that 
they  may  the  better  overcome  resistance.  The  better  patterns  are  made 
from  spiral  metal  so  constructed  as  to  assist  a  catheter  in  following  a  tort- 
uous canal. 


Figure  1263.    Otis'  Elastic  Catheter  Guide. 

Otis'  Elastic  Catheter  Guide,  as  exhibited  by  figure  1263,  consists  of  a 
steel  wire  about  6  inches  in  length  terminating  in  a  slender  spiral  elastic 
section  about  6  inches  in  extent,  the  two  pieces  united  by  a  screw  joint. 
The  tip  of  the  instrument  is  slightly  bulbous.  This  is  necessary,  not  only 
to  prevent  the  instrument  from  piercing  the  catheter,  but  to  avoid  injury 
to  the  mucous  surface  of  the  urethra  when,  as  sometimes  happens,  the  tip 
passes  out  through  the  eye  of  the  catheter.  The  catheter  should  be  some- 
what shorter.  It  may  be  slightly  stretched  and  the  proximal  end  turned 
over  an  acorn-shaped  bulb  that  forms  part  of  the  guide. 

Metallic  Elastic  Catheters  are  formed  by  spiral  bands  wound  upon  a 
mandril.  These  instruments  were,  at  one  time,  quite  extensively  used, 
but  are  now  seldom  employed.  Their  theory  of  construction  is  good ;  in 
practice,  however,  they  do  not  give  satisfaction.  They  become  rough  after 
a  little  use,  and  if  bent  abruptly,  openings  are  formed  between  the  spiral 


CATHETERS.  543 

sections,  that  not  only  tend  to  injure  the  mucous  surface,  but  render  the 
instrument  liable  to  break.  Further  than  this,  it  is  almost  impossible  to 
cleanse  them,  as  they  afford  every  opportunity  for  infection. 


DAUX,  MKNE  i  CO. 


Figure  1264.    Gross'  Spiral  Metal  Elastic  Catheter. 


Gross'  Spiral  Catheter,  as  indicated  by  figure  1264,  exhibits  one  of  the 
spiral  instruments  above  described.  Owing  to  their  peculiar  construction 
they  can  be  obtained  only  in  a  limited  number  of  sizes. 

Rigid  Catheters  are  the  ordinary  forms  of  metallic  instruments,  the 
degree  of  rigidity  depending  on  the  metal  selected.  They  may  be  of  silver, 
German  silver,  brass  or  block  tin.  Formerly  silver  catheters  were  exten- 
sively used,  but,  as  the  walls  were  usually  thin,  they  were  easily  bent  and 
broken.  This  was  particularly  true  of  those  jointed  for  pocket  case  use, 
for  when  crowded  against  instruments  or  other  firm  material,  they  would 
often  yield  to  pressure. 

German  silver  is  an  ideal  substance  for  metallic  catheters,  but  should 
always  be  silver  plated.  Nickel,  it  should  be  remembered,  is  not  a  good 
material  for  catheter  coating,  or,  in  fact,  for  any  instrument  which  requires 
occasional  bending,  because  the  nickel  forming  the  surface  is  non -elastic, 
and  easily  cracks  and  scales.  For  this  reason  it  is  not  adapted  for  metal 
catheters,  because  it  is  frequently  necessary  to  change  the  curve  of  such 
instruments  to  meet  special  conditions. 

Block  tin,  while  soft  and  flexible,  is  but  little  employed,  probably 
because  the  material  is  so  soft  that,  after  being  curved  it  easily  becomes 
roughened  and  uneven.  They  should  be  constructed  with  what  is  called 
an  aseptible  tip.  This  is,  we  believe,  the  invention  of  Prof.  Gross.  It 
consists  in  filling  in  with  some  kind  of  metal  the  space  that  lies  between 
the  eye  and  distal  margin  of  the  lumen. 

This  feature  will  be  understood  by  referring  to  figure  1265.  Usually 
melted  lead,  brass,  or  some  similar  metal  is  employed.  Catheters  thus 
constructed  are  more  easily  sterilized  than  the  ordinary  patterns. 


Figure  1265.    Gross  Metallic  Catheter  Tip. 

Usually  a  small  ring  is  attached  to  the  proximal  end  in  order  to  mark 
the  side  corresponding  to  the  outer  curved  surface  and  as  a  means  of  fast- 
ening the  catheter  in  cases  where  it  is  necessary  to  secure  permanent 
drainage.  They  should  always  be  used  with  caution,  as  otherwise  lacera 
tion  or  inflammation  of  tissue  may  result.  Small  sizes,  such  as  those 
below  No.  8  American  scale  are  considered  dangerous  by  many  because 
of  the  liability  of  injury  in  case  any  obstruction  to  the  passage  of  the 
catheter  is  encountered.  In  general  use  there  are  but  two  forms,  the 
normal  urethral  curve  and  the  prostatic  curve.  A  variety  called  "verte- 
brated"  was  at  one  time  recommended  by  some  authors.  Its  high  price, 


544 


GENITOURINARY    SURGERY. 


the  danger  of  separation  of  its  joints  and  its  inferiority  to  elastic  patterns 
led  to  its  abandonment  several  years  ago,  although  it  is  still  recommended 
in  many  modern  text  books. 

The  Normal  Urethral  Curved  Metallic  Catheter  is  usually  12  or  13 
inches  in  length.  The  vesical  end  should  be  curved  to  a  quarter  circle 
having  a  diameter  of  about  3^  inches. 


Figure  1266.    Ordinary  Metal  Male  Catheter. 

Ordinary  .Metal  Male  Catheters,  as  shown  in  figure  1266,  are  usually 
constructed  with  what  is  known  as  the  normal  urethral  curve  before  men- 
tioned. They  may  be  procured  in  either  sterling  silver,  brass,  or  German 
silver,  the  latter  being  usually  preferred.  In  numbers  they  generally  range 
from  4  to  20,  American  scale. 


Figure  1267.    Prostatic  Catheter. 

Prostatic  Catheters,  as  illustrated  in  figure  1267,  are  usually  15  to  16 
inches  in  length,  the  circle  representing  a  radius  of  3  inches  with  a  segment 
of  about  -fa  of  an  inch.  They  are  usually  employed  in  large  sizes,  because 
experience  has  demonstrated  that  such  instruments  will  more  readily 
pass  prostatic  obstructions.  While  occasionally  manufactured  from 
silver,  they  can  ordinarily  be  obtained  only  in  plated  brass.  The  sizes 
generally  vary  from  8  to  16  American  scale. 


Figure  1268.    Jointed  Male  and  Female  Catheter. 


Male  and  Female  Catheters,  as  displayed  by  figure  1268,  are  particu- 
larly adapted  for  pocket  case  use.  They  comprise  tips  for  both  male  and 
female  use. 


CATHETERS. 


545 


Parker's  Male  and  Female  Catheter  is  illustrated  by  figure  1269.  This 
instrument,  judging  from  its  extensive  sale,  would  seem  to  be  a  popular 
pattern.  It  is  usually  of  firm  construction  and  has  a  double  joint,  that  it 
may  be  carried  in  a  short  pocket  case.  An  additional  feature  in  the  way 


Figure  1269.    Parker's  Male  and  Female  Catheter  with  Caustic  Holder. 

of  a  caustic  holder  is  attached.  This  combination  is  of  doubtful  utility, 
for  unless  the  instrument  is  of  solid  silver  it  is  hardly  a  safe  means  of  carry- 
ing stick  caustic.  If  it  is  found  necessary  to  provide  for  the  transportation 
of  caustic,  it  would  be  better  to  have  a  caustic  holder  especially  constructed 
for  the  purpose. 

Catheters  Tied  In. 

This  is  sometimes  necessary  in  cases  of  injury  to  the  urethra,  drainage 
for  fistula,  stricture,  etc.  It  may  be  accomplished  by  adhesive  strips  passed 
around  the  penis,  to  which  threads  may  be  attached,  or  by  an  elastic  penis 
band  of  special  construction. 


Figure  1270.    Elastic  Penis  Band  or  Catheter  Holder. 

The  Elastic  Catheter  Holder,  as  shown  by  figure  1270,  consists  of  an  espe- 
cially devised  band  arranged  to  attach  the  proximal  end  of  a  catheter  to 
the  penis.  Practically  they  consist  of  two  flat  rubber  bands  passing  in 
opposite  directions  along  the  sides  and  around  the  end  of  the  penis. 
Where  they  cross  over  the  meatus,  they  are  perforated  by  a  minute  open- 
ing. The  bands  being  elastic,  they  furnish  the  means  for  holding  any 
catheter  that  may  be  passed  through  them.  As  they  are  capable  of  adjust- 
ment, any  degree  of  elastic  pressure  on  the  external  surface  of  the  organ 
may  be  obtained. 

Catheter  Boxes. 

Boxes  should  be  provided  for  the  transportation  of  catheters  and 
bougies.  They  may  be  straight,  in  which  the  instruments  may  be  placed 
full  length,  or  circular,  in  which  the  catheters  may  be  closely  coiled.  The 
former  are  preferable  and  should  be  adopted  wherever  possible,  because  all 
forms  of  elastic  catheters  will  prove  more  serviceable  and  lasting  if  always 
kept  straight. 

The  Papier  Mache  Catheter  Box,  as  set  forth  in  figure  1271,  is  usually 

35 


546 


GENITO-URIXARY  SURGERY. 


about  16  inches  in  length,  oval,  about  \%  inches  wide  by  il/2  inches  thick 
and  provided  with  a  slip-over  cover. 


Figure  1271.     Papier  Mach§  Catheter  Boxes. 


Figure  1272.     Circular  Catheter  Box. 


The  Circular  Catheter  Box,  as  outlined  in  figure  1272,  is  a  round  metallic 
box  with  oval  edges,  usually  from  2^  to  3  inches  in  diameter  and  i  inch 
thick.  In  this  two  or  three  catheters  may  be  coiled  and  transported  in  a 
small  space. 

Puncture  of  the  Bladder. 

This  operation  is  necessary  in  certain  cases  to  relieve  the  bladder  from 
over-distention.  But  two  methods  are  commonly  employed,  supra-pubic 
and  rectal. 

Supra-Pubic  Puncture  may  be  secured  either  by  aspiration  or  the  trocar. 
Aspiration  is  described  by  figures  371  10374.  It  should  be  remembered, 
however,  that,  in  introducing  an  aspirating  needle  into  the  bladder,  it  is 
advisable  to  first  make  a  short  incision  in  the  skin,  through  which  the 
needle  may  be  forced  backward  and  downward,  piercing  the  bladder  wall 
in  an  oblique  direction,  thus  forming  a  valvular  entrance.  When  the  needle 
is  withdrawn,  this  will  be  found  advantageous,  because  the  mucous  mem- 
brane flap  formed  by  the  flat  surface  of  the  needle  point  will  close  the 
opening  in  the  muscular  coat,  thus  preventing  urine  extravasation  in 
many  cases. 

In  supra-pubic  puncture  by  trocar,  the  introduction  should  follow  the 
lines  above  given  in  connection  with  the  aspirating  needle.  If  for  per- 
manent drainage,  however,  no  such  precautions  are  necessary.  In  such 
cases  a  new  soft  rubber  catheter  should  be  first  selected  that  fits  loosely  the 
lumen  of  the  canula.  It  is  better  if  the  trocar  have  two  linear  edges  instead 
of  being  triangular.  After  introduction  the  trocar  may  be  withdrawn, 
the  catheter  introduced  and  the  canula  removed.  The  catheter  may  be 
allowed  to  remain  in  place  indefinitely,  care  being  taken,  however,  that 
the  rubber  does  not  decompose  nor  become  closed  by  lateral  pressure. 
As  plain  trocars  have  been  fully  described  by  figures  377  to  381  we  will 
include  in  this  chapter  only  such  as  relate  exclusively  to  tapping  of  the 
bladder. 

Tapping  per  Rectum  is  preferred  by  some  operators,  because  it  furnishes 
perfect  bladder  drainage.  The  objection  to  this  procedure  is  that  it  can  not 
be  long  maintained  as  a  seat  for  permanent  drainage.  The  operation  is 
usually  performed  with  a  curved  trocar,  although  straight  trocars  are  occa- 
sionally employed.  The  former  do  not  differ  from  the  straight  patterns, 
excepting  that  they  are  longer  and  curved.  Like  the  latter,  they  may  be 
procured  of  any  size.  Those  of  better  grade  are  supplied  with  a  metal 


PUNCTURE  OF  THE  BLADDER.  547 

handle  and  a  cap  fitting  closely  over  the  distal  end  of  the  canula,  thus  pre- 
venting injury  to  the  trocar  point. 


Figure  1273.     Plain  Curved  Trocar. 

The  Plain  Curved  Trocar,  as  displayed  in  figure  1273,  usually  repre- 
sents the  arc  of  a  circle  whose  radius  is  about  4  inches,  the  length  of  the 
instrument,  excluding  the  handle,  being  about  6  inches.  Generally,  they 
are  about  No.  10  American  scale. 


Figure  1274.    Kuechenmeister's  Curved  Trocar  with  Injecting  Tube. 

Kuechenmeister's  Curved  Trocar,  as  is  apparent  in  figure  1274,  consists 
of  a  curved  puncturing  stylet  with  a  double-current  canula.  The  latter  is 
so  constructed  that  while  the  canula  is  in  situ  it  may  be  used  as  a  means 
for  flushing  or  irrigating  the  bladder.  The  instrument  is  usually  of  the 
same  length  and  size  as  the  regular  pattern. 


Figure  1275.    Curved  Trocar  with  Extra  Drainage  Canula. 

The  Curved  Trocar,  as  sketched  in  figure  1275,  is  a  trocar  of  the  regular 
pattern  with  two  canulas.     One  of  the  latter  is  of  the  regular  form,  while 


548 


GENITOURINARY    SURGERY. 


the  second  one  is  perforated  for  some  distance  from  its  vesical  end,  that  it 
may  be  utilized  as  a  drainage  tube. 


Figure  1276.    Harrison's  Perineum  Trocar. 

Harrison's  Perineum  Trocar  consists  of  a  straight  canula  arranged  with 
a  point  and  stylet  in  such  a  manner  that,  on  penetrating  a  cavity  containing 
fluid,  a  flow  through  the  instrument  is  at  once  secured.  As  pictured  in 
figure  1276,  the  canula  and  trocar  are  shown  attached  to  a  handle,  through 
which  passes  an  extension  of  the  inner  or  fluid-conducting  tube.  It  is 
intended  to  be  introduced  into  a  bladder  already  filled  with  fluid.  Previous 
to  introduction,  a  metal  catheter  is  passed  for  purpose  of  location,  fluid 
not  being  allowed  to  pass  out.  The  canula  is  supplied  with  a  sliding  collar, 
that  it  may  be  adjusted  to  different  thicknesses  of  tissue.  To  this  a  peri- 
neal  bandage  may  be  attached,  as  may  also  a  tube  for  conducting  escaping 
urine  to  any  selected  vessel.  Its  inventor  claims  that  this  method  of 
reaching  the  bladder  through  an  enlarged  prostate  is  attended  with  many 
advantages.  The  instrument  not  only  gives  notice  when  a  mass  of  fluid 
is  tapped,  but  its  canula  may  be  used  for  drainage. 

Incontinence  of  Urine. 

Incontinence,  or  lack  of  control  over  the  bladder  contents,  frequently 
results  in  continued  dribbling  of  urine.  During  treatment,  or  if  incurable, 
the  patient  should  be  supplied  with  some  pattern  of  portable  urinal.  These 
may  be  procured  for  both  males  and  females. 

Portable  Urinals  for  Males. 

These  are  so  constructed  that  they  may  be  worn  under  the  clothing  with- 
out much  inconvenience.  Others  are  designed  for  use  either  day  or  night,  for 
which  purpose  they  appear  to  meet  all  requirements. 

Soft  Rubber  Urinals  for  Males,  as  set  forth  in  figure  1277,  maybe  procured 
of  several  patterns.  "A,"  "B,"  "C"  and  "D"  illustrate  those  in  common  use. 
'  'A' '  is  provided  with  a  funnel-shaped  opening  so  constructed  as  to  include  the 
penis,  and  through  which  the  urine  is  conducted  to  the  receiving  bottle  below. 
Between  the  funnel  and  the  bottle  a  soft  rubber  valve  is  provided,  by  means 
of  which,  should  the  bag  become  temporarily  inverted,  the  urine  will  not 
be  spilled.  A  screw  cap  at  the  lower  opening  of  the  chamber  permits  the 
withdrawal  of  the  urine  from  time  to  time.  A  band  is  provided  by  which 
the  bag  may  be  attached  to  the  thigh. 

Figure  "B"  differs  from  "A"  in  the  construction  of  the  upper  portion, 
which,  in  this  case,  is  enlarged  into  a  funnel-shaped  bag  that  fits  closely 
around  the  entire  external  genitals.  This  is  not  only  provided  with  a  waist- 
band, but  also  with  a  perineal  band,  by  means  of  which  the  part  immediately 
including  the  scrotum  is  held  in  place. 

Figure  "C"  differs  from  "B, "  more  especially  in  having  the  bag  connected 


INCONTINENCE    OF    URINE. 


549 


with  the  upper  portion  by  means  of  a  rubber  tube  about  18  inches  in 
length.  When  in  bed  this  bag  may  be  suspended  outside  the  clothing  to 
receive  all  escaping  urine. 


A  B  CD 

Figure  1277.    Portable  Soft  Rubber  Urinals  for  Males. 

Figure  "D"  provides  a  long  slender  bag  extending  well  down  the  inner 
margin  of  the  leg  and  supplied  with  two  bands,  that  it  may  more  readily 
be  held  in  position.  This  pattern  is  well  adapted  for  day  use,  as  it  need 
not  show  through  the  clothing. 

Portable  Urinals  for  Females. 

These  differ  from  those  just  described  only  in  the  shape  of  the  pefineal 
cup  or  funnel-shaped  opening. 


Figure  1278.    Portable  Soft  Rubber  Urinals  for  Figure  1279.    Urinal  for  Bladder  Exstrophy. 

Females. 

Portable   Soft  Rubber   Urinal   for    Females,  as    they   appear   in  figure 
1278,  are  constructed  with  a  cup  or  funnel-shaped  opening,  which,  in  these 


550  GENITOURINARY    SURGERY. 

patterns,  is  made  to  conform  closely  to  the  perineum  and  lower  abdominal 
surfaces,  the  cup  being  held  in  position  by  straps  leading  to  a  waistband. 
Like  the  former  patterns,  the  bags  are  attached  to  the  thigh  by  suitable 
straps. 

Exstrophy  of  the  Bladder. 

In  connection  with  this  subject  we  shall  only  exhibit  a  single  urinal, 
which  may  be  provided  for  cases  of  this  character.  In  the  absence  of,  or 
following  surgical  interference,  these  may  be  constructed  of  such  form 
and  material  as  desired.  Usually  makers  demand  that  a  plaster  cast  of 
the  surface  to  be  covered  by  the  urinal  rim  be  furnished  them. 

Urinal  for  Bladder  Exstrophy  may  be  of  various  patterns.  That  dis- 
played by  figure  1279  consists  of  a  cup-shaped  shield,  either  of  silver  or 
copper  so  swaged  and  formed  that,  when  tightly  strapped,  it  will  fit  closely 
to  the  contour  of  the  external  genitals.  The  rim  or  contact  surface  should 
surround  the  bladder,  extending  beyond  its  lateral  margins,  and  including 
the  point  of  exudation.  The  lower  portion  of  the  cup  may  be  enlarged  into 
a  bowl  of  sufficient  size  to  contain  the  discharge  of  urine  for  ten  to  twelve 
hours,  or  an  outlet  pipe  may  be  provided  that  will  connect  with  a  rubber 
bag  similar  to  the  designs  shown  by  figure  1277. 

Foreign  Bodies  in  the  Bladder. 

Foreign  bodies  that  find  their  way  into  the  bladder  embrace  a  large 
number  of  articles.  They  consist  of  calculi,  pieces  of  catheters  and 
bougies,  hairpins,  slate  pencils,  spiculae  of  bone  from  pelvic  fractures, 
projectiles,  pieces  of  clothing  carried  in  through  gunshot  wounds,  etc. 
They  are  much  more  frequent  in  the  female,  but  owing  to  the  short  and 
easily-dilated  urethra  they  are  not  so  difficult  to  remove. 

An  attempt  to  extract  a  foreign  body  may  be  made  as  soon  as  its  nature 
is  known.  If  it  entered  the  bladder  through  the  urethra,  it  may  be  taken 
out  through  the  same  opening,  if  it  can  be  correctly  seized.  Various 
forms  of  instruments  are  in  use  for  extraction.  If  the  body  be  grasped, 
its  relations  with  the  instrument  and  urethra  may  be  determined  by  digital 
examination.  Pieces  of  soft-rubber  catheters,  which  are  the  most  common 
of  foreign  bodies,  may  usually  be  extracted,  no  matter  how  caught. 

Usually  such  foreign  bodies  may  be  removed  by  a  lithotrite  or  a  special 
instrument  constructed  for  this  purpose.  In  cases  of  females  or  where  a 
cystotomy  is  necessary,  the  longer  articles  may  be  cut  into  pieces  of 
shorter  length.  A  correct  diagnosis  frequently  necessitates  the  use  of  the 
cystoscope. 


Figure  1280.    Mercier's  Bladder  Instrument  for  Removing  Foreign  Bodies. 


Mercier's  Instrument  for  Removing  Foreign  Bodies  from  the  Bladder,  as 

manifest  by  figure   1280,  consists  of  a  slotted  tubular  shaft  provided  with 
a  central  double-grooved  part,  the  whole  forming  a  smooth  circular  rod 


WASHING    OUT    THE    BLADDER. 


551 


when  closed.  The  shaft  of  the  instrument  terminates  in  an  angular,  some- 
what scoop-shaped  beak,  provided  upon  its  distal  surface  with  a  narrow  slot. 
The  central  rod  is  also  bent  at  the  same  angle,  the  two  beaks  forming  a 
jaw  that  may  be  opened  or  closed  by  actuating  the  handle.  The  distal  side 
of  this  beak  is  elongated  into  a  spear-shaped  projection  that  fits  into  and 
passes  through  the  narrow  slot.  The  instrument  is  evidently  patterned 
after  a  lithotrite,  differing  from  the  latter  principally  in  the  shape  of  the 
jaws.  They  are  so  constructed  that,  with  ordinary  care,  the  wall  of  the 
bladder  need  not  be  included  in  the  grasp  of  the  instrument.  It  may  be 
introduced  through  the  urethra,  male  or  female,  a  set  screw  being  provided, 
by  means  of  which  the  jaws  may  be  held  in  proper  position  for  passage 
through  the  canal. 


Figure  1281.    Alligator  Bladder  Forceps. 


Alligator  Bladder  Forceps,  as  indicated  by  figure  1281,  and  intended  for 
the  removal  of  foreign  bodies  from  the  bladder  per  urethram,  have  the 
normal  urethral  curve.  The  points  are  well-smoothed  and  rounded  to  avoid 
injury  to  the  mucous  lining  of  the  urethra.  The  instrument  is  constructed 
on  the  double-lever  principle,  and  so  adjusted  that  a  slight  spreading  of  the 
long  handles  produces  a  like  movement  in  the  forceps  blades.  The  instru- 
ment should  be  of  such  length  that  it  may  be  passed  within  the  bladder. 

Flushing  or  Washing  Out  the  Bladder. 

This  may  be  secured  by  various  methods,  a  catheter  connected  with 
some  form  of  syringe  or  hydrostatic  power  usually  furnishing  the  means. 
Almost  any  bulb,  fountain  or  siphon  syringe  may  be  used,  the  two  latter 
being  preferred. 


Figure  1282.    Van  Buren's  Bladder-washing  Apparatus. 

Van  Buren's  Bladder-washing  Apparatus,  as  set  forth  in  figure  1282, 
consists  of  a  fountain  syringe  attached  to  a  soft  rubber  catheter  by  means 
of  a  two-way  stop-cock.  By  a  two-way  stop-cock  is  meant  one  in  which  the 


E   01- 


552 


GENITOURINARY    SURGERY. 


fluid,  after  entering  the  cock,  may  be  emitted  in  either  of  two  directions. 
Strictly  speaking,  the  cock  has  three  openings,  through  only  one  of  which 
the  fluid  can  enter.  In  other  words,  it  has  one  inlet  and  two  outlet  pipes. 
The  catheter  is  introduced,  and  the  cock  turned  so  that  the  fluid  passes 
directly  through  the  syringe  to  the  bladder.  After  the  latter  has  been  filled, 
the  connection  with  the  syringe  may  be  closed  and  the  fluid  forced  through 
the  side  outlet  of  the  stop-cock  by  the  natural  contractile  power  of  the  blad- 
der. This  operation  may  be  repeated  as  often  as  necessary. 


Figure  1283.    Soft  Rubber  T-Pipe  with  Catheter. 


Figure  1584.     Wigmore's  Irrigating  Pipe,  for  Use  in 
Bladder. 


The  Soft  Rubber  T-Pipe,  exhibited  by  figure  1283,  consists  of  a  piece 
of  rubber  tubing  in  T-shape.  The  straight  section  may  form  the  connec- 
tion between  a  fountain  syringe  and  a  catheter.  During  the  filling  of  the 
bladder  the  lower  or  dependent  portion  of  the  T  may  be  closed  by  stop-cock 
or  other  means.  The  bladder  may  be  evacuated  by  closing  the  connection 
leading  to  the  reservoir  and  opening  the  escape  pipe. 

Wigmore's  Irrigating  Pipe  for  use  in  the  bladder,  as  illustrated  in  fig- 
ure 1284,  consists  of  a  metallic  bifurcated  tube.  The  distal  end  of  the 
main  tube  is  arranged  for  attachment  to  a  soft  rubber  catheter.  The  proxi- 
mal end  contains  a  sliding  stop,  by  which  connection  with  the  lower  arm 
may  be  cut  off.  This  section  may  be  attached  to  a  fountain  syringe  and 
the  bladder  irrigated  through  the  straight  portion  of  the  pipe.  As  soon  as 
the  bladder  is  filled,  the  inner  tube  is  withdrawn,  whereupon  the  bladder 
contents  escape  through  the  catheter  and  lower  arm  of  the  instrument.  It 
is  of  metal  and  about  3  inches  in  length. 


Figure  1285.     Peck's  Bladder  Syringe. 

Peck's  Bladder  Syringe,  as  pictured  in  figure  1285,  is  usually  made  by 
attaching  a  stop-cock  with  a  conical  tip  to  each  end  of  a  6-ounce  Politzer 
bag.  To  one  of  these  cocks  a  catheter  may  be  attached,  while  a  piece  of 
rubber  tubing  may  be  connected  with  the  second.  When  in  service,  the 
catheter  may  be  introduced  and  the  syringe  attached.  The  latter  may  be 
filled  before  or  after  connection  is  made.  By  means  of  the  cut-off  connect- 
ing with  the  catheter  the  flow  may  be  stopped  at  any  time.  The  bulb  may 
be  filled  or  its  contents  expelled  by  means  of  the  stop-cock  in  the  rear.  After 
being  filled,  the  latter  may  be  closed,  the  catheter  stop-cock  opened,  and 


s  n , 


fjHJJG 


WASHING    OUT    THE    BLADDER. 


553 


the  contents  of  the  bulb  injected.     The  instrument  may  be  used  in  various 
ways,  either  for  injecting  or  exhausting. 


Figure  1286.    Van  Buren's  Bladder  Syringe. 

Van  Buren's  Bladder  Syringe,  as  outlined  by  figure  1286,  differs  from 
the  pattern  of  Peck,  previously  described,  in  being  constructed  with  but  a 
single  stop-cock.  As  the  capacity  of  the  bulb  is 'from  4  to  6  ounces,  it  is 
suitable  for  ordinary  injections. 


Figure  1287.    Ultzmann's  Hard  Rubber  Bladder  Syringe. 

Ultzmann's  Bladder  Syringe,  as  shown  in  figure  1287,  consists  of  a 
hard  rubber  piston  syringe  of  the  usual  type  and  of  6-ounce  capacity.  It  is 
provided  with  a  conical  tip,  that  it  may  be  connected  with  a  soft  rubber 
catheter.  As  it  is  constructed  with  a  ring  handle  and  a  large  curved  finger 
hold,  it  may  be  manipulated  with  one  hand. 

Double-channel  Catheters. 

These,  as  their  name  implies,  consist  of  tubes  divided  throughout  their 
length,  so  as  to  form  two  channels,  one  in-flowing,  the  other  out-flowing. 
As  a  rule,  the  evacuating  channel  is  the  larger,  as  there  is  thus  less  danger 
of  its  becoming  occluded.  Usually  the  openings  of  the  two  canals  are  near 
the  tip.  This  is  particularly  true  of  the  in-flowing  current.  They  are  con- 
structed of  metal,  hard  rubber,  celluloid,  elastic  web  and  soft  rubber,  the 
latter  being  usually  employed. 


Figure  1388.     Metallic  Double-channel  Catheter. 


The  Metallic  Double-channel  Catheter,  as  illustrated  by  figure  1288,  is 
in  size  usually  about  Number  17,  French  scale,  and  may  be  obtained 
either  of  silver  or  of  brass  silver-plated.  Two  patterns  may  be  found 
in  the  market,  one  in  which  each  of  the  channels  terminates  in  an  eye, 


554 


GENITOURINARY    SURGERY. 


the  same  as  in  the  ordinary  form  of  catheter,  while  a  second  one,  devised 
by  Nott,  is  provided  with  lateral  fenestrae,  both  of  which  form  the  exit 
for  the  out-flowing  current. 


Figure  1289.    Marcy's  Double-channel  Catheter. 

Marcy's  Double-channel  Catheters,  as  outlined  by  figure  1289,  consists 
of  a  double-channel,  soft  rubber  catheter  of  the  usual  type,  to  the  out-flow- 
ing channel  of  which  an  escape  pipe  is  secured  by  a  T-shaped  attach- 
ment. By  connecting  the  instrument  with  a  fountain  syringe,  a  continuous 
flow  into  and  out  of  the  bladder  may  be  secured.  The  discharged  fluid 
may  be  conducted  into  any  desired  receptacle  by  a  piece  of  tubing. 

Applications  to  the  Bladder. 

These  may  be  administered  by  means  of  special  catheters,  suppository 
carriers,  granule  carriers,  etc.  No  appliances  are  included  under  this  head 
that  are  not  introduced  directly  into  the  bladder.  Those  that  employ  force 
to  overcome  the  vesical  sphincter  are  included  under  urethral  instruments. 


Figure  1290.    Bigelow's  Syringe  Catheter. 

Bigelow's  Syringe  Catheter,  as  outlined  in  figure  1290,  consists  of  a 
silver  tube,  double-channeled  and  in  catheter  form.  The  second  channel 
is  formed  by  a  slender  pipe  contained  within  the  larger  one,  having  its 
vesical  opening  in  the  center  of  the  catheter  tip.  The  in-flowing  current, 
or  that  from  the  syringe,  passing  through  the  main  channel,  finds  its  exit 
in  numerous  minute  openings,  located  upon  all  sides  of  the  catheter  end. 
As  the  return  channel  is  much  smaller  than  the  in-flowing  one,  the  instru- 
ment is  adapted  only  for  applications.  It  is  constructed  of  silver  and  is 
so  arranged  that  it  can  be  attached  to  a  syringe. 


_  > 

A 


Figure  1291.    Harrison's  Bladder  Suppository  Carrier. 

Harrison's  Suppository  Carrier,  as  detailed  in  figure  1291,  combines  a 
catheter  and  a  carrier.  The  instrument  consists  of  a  stylet  within  a 
metallic  catheter,  so  constructed  that  suppositories,  granules,  etc.,  may  be 
deposited  in  the  bladder.  A  small  plunger-like  head  on  the  end  of  the 
stylet  furnishes  the  means  by  which  solid  and  semi-solid  medicaments  may 
be  pushed  through  the  lumen  of  the  catheter.  A  screw-cap  fitting  closely 


LITHOLOPAXY.  555 

around  the  stylet  prevents  accidental  separation.  A  fork,  in  the  lumen  of 
the  tube,  and  eyes,  in  the  vesical  end,  allow  the  urine  to  pass  out  of  the 
bladder  through  the  catheter. 


Figure  1292.    Lee's  Granule  Applicator  for  Use  in  the  Bladder. 


Lee's  Granule  Applicator,  as  set  forth  in  figure  1292,  differs  from  the 
model  of  Harrison,  last  described,  in  being  constructed  with  an  upper  fork 
in  the  canal,  by  means  of  which  granules  may  be  introduced  into  the  canal 
without  detaching  the  stylet. 

Litholopaxy. 

As  this  procedure  necessitates  a  lithotrite,  no  separate  mention  of  the 
latter  is  required.  This  operation  has  largely  replaced  the  various  methods 
of  cystotomy.  The  instruments  necessary  consist  of 

Lithotomy  sound  or  cystoscope,  for  examinations,  figures  1250  to  1253. 

Lithotrite,  for  crushing  calculi. 

Evacuating  apparatus,  for  removal  of  fragments. 

Steel  sounds,  for  determining  patency  of  urethra,  figures  1359  to  1364. 

Lithotrites. 

These  are  long,  slender  instruments  provided  with  strong,  curved  jaws, 
controlled  by  screw  power,  and  adapted  for  crushing  vesical  calculi  through 
the  urethra. 

A  lithotrite  should  be  manufactured  with  the  greatest  of  care ;  the  larger 
ones,  used  for  crushing  entire  and  heavy  stones,  should  be  cut  or  formed 
from  a  bar  of  solid  steel.  Forgings  contain  a  percentage  of  flaws  or  cracks, 
and  the  breaking  of  an  instrument  of  this  class  during  an  operation  would 
prove  so  serious  a  mishap  that  all  possible  risk  must  be  excluded.  As  a 
precaution  all  lithotrites  should  be  tested  upon  pieces  of  sandstone  previous 
to  operating.  A  fragment  the  size  of  a  walnut  will  be  found  to  answer  the 
purpose. 

As  usually  constructed,  they  consist  of  a  grooved  steel  shaft  enclosing  a 
flattened  bar,  the  two  formed  and  slotted  so  that  they  readily  slide  one 
within  the  other,  and  when  united  present  a  smooth  round  surface.  The 
better  patterns  are  constructed  so  that  the  blades  may  be  closed  by  a  slid- 
ing motion,  at  least  until  the  stone  is  grasped  between  them,  when,  by 
proper  mechanism,  screw  power  may  be  brought  into  action  and  the  stone 
crushed  by  forcible  approximation.  As  this  form  will  not  admit  of  as  fine 
crushing  as  often  desired,  small  lithotrites  with  flat  and  solid  blades  are 
often  employed. 

The  contact  surface  of  the  moving  or  male  blade  is  usually  cut  into  a 
series  of  pyramidal  cusps,  the  recesses  between  each  acting  as  a  wedge  by 
means  of  which  the  fragments  of  stone  are  pushed  or  crowded  to  each  side. 
Before  introduction  the  urethra  is  usually  dilated  by  means  of  graduated 
sounds. 

If  a  single  instrument  be  relied  upon,  it  should  be  so  constructed  that  it 
will  crush  the  stone  into  fine  fragments,  as  the  comminution  should  be 


556 


GENITOURINARY    SURGERY. 


extreme.  A  size  should  be  selected  as  large  as  the  urethra  will  admit. 
Usually  the  outer  or  female,  is  wider  than  the  male  blade,  so  that  the 
mucous  folds  of  the  bladder  may  not  be  cut  or  lacerated  between  them. 
The  female  blade  of  the  larger  instruments  is  usually  fenestrated  in  order 
to  prevent  the  jaws  from  becoming  impacted  with  stone  fragments.  Such 
an  accident,  unless  the  pieces  were  successfully  dislodged  would  mean  the 
laceration  of  tissues,  or  would  necessitate  a  cystotomy. 


Figure  1293.     Bigelow's  Lithotrite. 


Bigelow's  Lithotrite,  as  exhibited  in  figure  1 293,  is  more  largely  employed 
than  any  other  pattern,  as  it  is  generally  conceded  that  there  is  less 
danger  of  its  becoming  clogged  by  fragment  impaction.  The  male  blade 
is  provided  with  pyramidal  projections  in  the  form  of  alternating  triangular 
notches,  the  lateral  inclined  planes  of  which  force  the  detritus  to  either  side, 
thus  keeping  the  blades  free  from  obstruction. 

That  the  instrument  jaws  may  be  accurately  fitted  together,  a  slot  is  pro- 
vided in  the  heel  of  the  female  blade,  into  which  a  projection  from  the  male 
blade  closely  fits.  The  tip  of  the  female  blade  is  slightly  bulbous  and 
curved  backward,  in  order  to  facilitate  its  urethral  passage.  The  rim  is 
made  low,  that  the  fragments  may  easily  escape  to  either  side.  This  also 
facilitates  the  grasping  of  a  stone.  The  actuating  power  is  simple  and 
effectual.  A  contraction  of  the  proximal  end  of  the  central  bar  permits  the 
attachment  of  a  cylinder,  the  outer  surface  of  which  is  threaded,  the  whole 
revolving  upon  the  inner  shaft.  The  main  shaft  of  the  instrument  is 
enlarged  by  a  circular  hand-piece,  within  which  are  two  steel  springs,  one 
upon  either  side,  each  containing  a  section  of  the  female  thread.  These 
threads  are  controlled  by  a  cam  movement,  so  that  by  simply  turning  a 
milled  wheel  slightly  to  the  right,  the  screw  threads  may  be  brought  into 
action  and  the  instrument  changed  from  a  sliding  to  a  screw  power. 

The  handle  is  large  and  egg-shaped,  thus  filling  the  hand.  Externally,  it 
presents  a  fluted  surface  that  furnishes  a  firm  grip.  Those  for  adults  are 
made  in  three  sizes,  Nos.  16,  18  and  20,  American  scale  while  for  chil- 
dren, sizes  10  to  13  are  employed. 


Figure  1294.    Thompson's  Lithotrite. 


Thompson's  Lithotrite,  as  traced  in  figure  1294,  as  now  constructed,  differs 
from  the  pattern  of  Bigelow  principally  in  the  method  of  changing  from  a 
sliding  to  a  screw  power.  The  shaft,  for  about  three  inches  at  its  proximal 
end,  is  enlarged  and  bears  a  male  thread.  This  thread  is  covered  with  a 
cylinder  that  is  provided  with  lateral  openings.  Opposite  these  openings, 
two  spring  catches  or  dogs,  provided  on  their  inner  margins  with  female 
threads,  are  caused  to  engage  the  male  portion  by  means  of  a  sliding  button 
arranged  on  the  upper  surface  of  the  instrument.  The  movable  jaw  may 
be  actuated  by  thumb-and-finger  movement.  This  may  be  used  for  grasp- 
ing the  stone  or  other  object  to  be  crushed  or  clasped,  after  which  recourse 
may  be  had  to  screw  power  by  drawing  the  thumb  slide  forward.  The  jaws 


CRUTr 

Children 

L1THOLOPAXY. 


Hospital. 


557 


of  this  instrument  are  now  constructed  with  plain  oblique  serrations  that 
meet  in  the  center  of  the  jaw,  forming  the  ridge  or  spine,  or  with  obliquely- 
cut  notches,  after  the  pattern  of  Bigelow,  previously  referred  to. 

Evacuating  Apparatus. 

These  usually  consist  of  soft  rubber  bulbs,  connected  with  suitable 
metallic  catheters,  and  provided  with  glass  reservoirs  into  which  the  sand 
or  crushed  stone  may  gravitate.  These  bulbs  are  generally  of  from  10  to 
12  ounce  capacity,  and  are  constructed  of  heavy  rubber.  Two  catheters  are 
usually  provided,  curved  and  straight,  each  with  a  large  eye  located  near 
the  tip. 

Operators  with  extensive  practice  usually  provide  themselves  with 
catheters  of  various  sizes  and  curves,  that  they  may  meet  the  requirements 
of  special  cases.  Straight  catheters  are  more  favorable  to  evacuation 
of  large  fragments,  while  curved  instruments  are  easier  of  introduction  in 
complicated  cases.  A  wing  or  other  projection  on  the  proximal  end  of  the 
catheter  marks  the  side  upon  which  the  opening  into  the  tube  is  located. 


Figure  1295.     Bigelow's  Improved  Evacuating 
Apparatus. 


Figure  12%.    Thompson's  Evacuating 
Apparatus. 


Bigelow's  Evacuating  Apparatus,  as  illustrated  by  figure  1295,  consists  of 
a  large  ovoid  bulb,  upon  one  side  of  which  an  arm  or  projection  forms  what 
might  be  termed  a  fork  in  the  canal.  The  main  portion  of  the  bulb  is  sup- 
plied at  both  ends  with  openings  and  metal  connections.  At  the  bottom  of 
one  end  a  small  fixed  glass  ball  is  arranged  to  receive  the  detritus. 

At  the  upper  end  a  metallic  shank,  in  which  a  stop-cock  is  located, 
terminates  in  funnel  form,  through  which  the  bulb  is  filled  with  fluid,  after 
which  the  stop-cock  is  closed.  The  side-fork,  previously  referred  to,  also 
terminates  in  a  metal  connection  with  the  shank  and  stop-cock.  This  points 
obliquely  downward,  and  is  the  part  to  which  the  catheters  are  attached  by 


558  GENITOURINARY    SURGERY. 

means  of  bayonet  joints.  These  catheters  are  usually  two  in  number — about 
No.  1 8  to  20,  American  scale — one  straight,  the  other  curved.  The  tube  or 
shank  to  which  these  catheters  are  attached  projects  into  the  center  of  the 
bulb,  usually  for  about  2  inches.  That  portion  of  the  tube  within  the  pro- 
jecting fork  is  provided  with  perforated  sides,  the  openings  being  small,  yet 
aggregating  in  area  far  more  than  the  lumen  of  the  end  of  the  tube. 
Fragments  of  stone  passing  upward  with  the  flow  of  water  are  carried 
through  the  tube,  dropping  into  the  water  in  the  lower  portion  of  the  bulb. 
Compression  of  the  bulb  forces  the  water  to  return  through  the  catheter ; 
but,  seeking  the  shortest  route,  it  rushes  through  the  small  side  openings, 
through  which  the  detritus  cannot  pass.  The  stone  fragments  are  thus  left 
in  the  bulb. 

Thompson's  Evacuating  Apparatus,  as  shown  by  figure  1296,  consists  of 
a  rubber  bulb  and  glass  reservoir  similar  in  construction  to  the  pattern  of 
Bigelow.  The  principal  point  of  difference  is  in  the  connection  of  the 
catheters,  which,  in  this  instrument,  is  made  direct  with  the  lower  portion 
of  the  instrument.  The  stop-cock  controls  the  flow  of  fluid  to  and  from  the 
catheter.  The  upper  portion  of  the  bulb  terminates  in  a  stop-cock  and 
small  funnel,  by  means  of  which  the  bag  may  easily  be  filled.  The 
catheters  are  two  in  number — one  curved  and  one  straight — usually  about 
No.  1 8,  American  scale. 

Cystotomy. 

Cystotomy  may  be  either  supra-pubic  or  perineal,  the  latter  being  more 
generally  known  as  lithotomy. 
Supra-pubic  Cystotomy  will  require  the  following: 

Minor  operation  instruments,  described  on  pages  270  to  275. 

Leg  holder,  for  securing  patient  in  proper  position,  figures  194  to  197. 

Petersen's  bag  or  colepurynter,  for  distending  rectum. 

Syringe  or  irrigator,  for  irrigating  the  bladder,  figures  1282  to  1289. 

Scissors  short  and  angular,  for  enlarging  primary  incision,  figure  925. 

Abdominal  retractors,  for  enlarging  the  field  of  vision,  figures  930  to  934. 

Tenacula,  for  holding  flaps  and  tissues,  figures  950  to  952. 

Needles,  for  closing  abdominal  wounds,  figures  057  to  960. 

Supra-pubic  drainage  tube. 

Abdominal  band,  for  support  after  operation,  figure  967. 
If  for  removal  of  calculi,  in  addition  to  the  above- 
Lithotomy  forceps,  for  removal  of  stones. 

Lithotomy  scoop,  for  removal  of  small  stones  or  fragments. 

Lithoclast  or  lithotrite,  for  breaking  up  large  stones. 
If  for  the  removal  of  tumors — 

Scissors,  long,  for  excision  of  pedicles,  etc. 

Spoons  or  curettes,  for  dislodging  tumors. 

Bladder  forceps,  for  avulsion  of  tumors. 

Ecraseurs,  knives,  cauteries,  etc.,  are  frequently  required, depending  on 
the  nature  of  the  disease.  Full  lists  of  these  latter  instruments  are  given 
in  a  chapter  devoted  to  the  treatment  of  uterine  myoma. 

Petersen's  Bag,  as  shown  by  figure  1297,  and  sometimes  called  a  col- 
peurynter,  is  used  to  distend  the  rectum  and  thus  elevate  the  bladder.  It 
consists  of  a  pear-shaped  rubber  bag,  usually  about  6  inches  in  length  and 
4  inches  in  diameter  at  the  largest  part,  one  end  of  which  connects  with  a 
rubber  hose  and  stop-cock.  After  being  well  smeared  with  oil,  it  may  be 
introduced  into  the  rectum,  passed  above  the  sphincters,  and  dilated  with 


SUPRA-PUBIC    CYSTOTOMY. 


559 


not  to  exceed  8  to  12  ounces  of  water  for  an  adult.  As  hand  pressure,  when 
exerted  on  a  syringe  bulb,  is  intermittent  and  unsafe,  hydrostatic  force  as 
found  in  the  action  of  a  fountain  syringe  is  to  be  preferred.  The  reservoir 
need  be  elevated  only  2  to  3  feet  above  the  rectum.  The  bag  should 


Figure  1297.    Petersen's  Bag. 


always  be  introduced  while  the  bladder  is  empty.  This  procedure  is  con- 
sidered by  some  operators  as  dangerous,  because  of  the  liability  of  lacerating 
the  mucous  membrane  or  rupturing  the  rectal  wall.  For  this  reason,  it  is 
seldom  employed  in  case  of  children. 

Lithotomy  Forceps. 

Forceps  are  employed  for  grasping  and  removing  calculi.  Usually,  they 
terminate  in  short,  broad,  bowl-shaped  blades,  the  concavity  being  provided 
with  means  for  holding  the  grasped  stone  securely.  The  handles  should 
all  be  double-crossing,  so  that,  in  case  of  a  deep  perineum,  they  may  be 
used  through  a  small  opening. 


Figure  1298.    Little's  Straight  Lithotomy  Forceps. 


Figure  1299.    Little's  Curved  Lithotomy  Forceps. 


Little's  Lithotomy  Forceps,  as  exhibited  by  figures  1298  and  1299,  are  the 
standard  instruments  for  the  removal  of  stone  from  the  bladder,  and  differ 
from  each  other  only  in  that  one  of  them  is  slightly  curved.  While  the  size 
should  be  in  proportion  to  the  diameter  of  the  stone  to  be  grasped,  they  are 
usually  about  9  inches  in  length,  the  inner  surfaces  of  the  concave  jaws 


560 


GENITOURINARY    SURGERY. 


being  provided  with  short,  sharp  teeth,  thus  affording-  a  good  grasping  sur- 
face to  hold  a  calculus. 

Lister  recommends  lining  the  blades  with  linen  cloth,  not  only  because 
the  latter  furnishes  a  good  grasping  surface,  but  tends  to  prevent  chip- 
ping of  small  pieces  from  .the  stones.  The  straight  pattern  is  all  that  is 
necessary  in  cases  where  the  bladder  is  of  normal  shape  and  size  and  the 
calculi  not  impacted. 

The  curved  pattern  will  be  found  desirable  for  reaching  calculi  in  the 
post-prostatic  pouch  and  in  dislodging  encysted  stones  not  within  reach  of 
the  straight  pattern.  A  special  size,  about  5  inches  in  length,  is  advised  for 
operations  on  children. 


Figure  1300;    Frank's  Curved  Lithotomy  Forceps. 

Frank's  Lithotomy  Forceps,  as  depicted  by  figure  1300,  differ  from  the 
patterns  of  Little  in  having  an  angular  bend.  They  will  be  found  useful 
in  cases  where  it  is  necessary  to  grasp  impacted  stones  that  lie  close  behind 
a  bulging  prostate. 

Lithotomy  Scoops. 

Scoops  are  employed  for  dislodging  encysted  calculi  and  removing  small 
stones,  debris,  etc.  It  is  advised  that  the  surgeon  provide  himself  with 
various  sizes  and  curves,  and  particularly  small  ones  for  use  when  operating 
on  children.  Some  authors  have  advised  that  scoops  be  constructed  curved  to 
the  right  and  to  the  left,  while  some  patterns,  to  avoid  multiplicity  of  instru- 
ments, have  a  scoop  constructed  upon  each  end  of  the  handle.  In  operations 
they  may  be  used  as  a  forceps  blade,  manipulation  and  extraction  being 
assisted  by  the  forefinger. 


Figure  1301.    Leur's  Lithotomy  Scoop. 

Leur's  Lithotomy  Scoop,  as  represented  by  figure  1301,  consists  of  a 
handle  and  shank  terminating  in  a  deep  and  somewhat  narrow  spoon,  the 
bowl  of  which  should  not  exceed  5/8  of  an  inch  in  transverse  diameter.  The 
terminal  margin  should  be  somewhat  elongated,  giving  the  spoon  the 
appearance  of  being  curved  on  the  flat.  The  whole  instrument  is 
usually  from  9  to  10  inches  in  length. 

Lithoclasts. 

These  are  a  form  of  forceps  designed  for  breaking  up  large  calculi  that 
they  may  be  more  easily  removed  through  a  small  opening. 

Dolbeau's  Lithoclast,  as  set  forth  in  figure  1302,  consists  of  a  strong 
forceps-shaped  instrument  provided  with  short  jaws,  particularly  designed 
for  breaking  large  stones  into  two  or  more  pieces.  The  center  of  each  jaw 
is  provided  with  a  short  ridge,  the  spine  of  which  is  covered  with  sharp, 


SUPRA-PUBIC    CYSTOTOMY. 


5G1 


short  teeth,  thus  exerting  a  somewhat  cutting  force  against  the  stone  to  be 
severed.     The  entire  instrument  is  about  10  inches  in  length. 


Figure  1302.    Dolbeau's  Lithoclast. 


Goulay's  Double-lever  Lithoclast,  consists  of  a  compound  lever  arranged 
to  act  within  a  limited  space.  The  duplicate  lever  is  not  intended  to 
furnish  additional  crushing  power,  but  rather  to  avoid  a  wide  separation  of 
the  handles  in  cases  where  it  is  necessary  to  grasp  a  large  calculus.  As 


Figure  1303.     Goulay's  Double-lever  Lithoclast. 

suggested  in  figure  1303,  the  jaws  are  short  and  slightly  curved  on  the  flat. 
The  contact  surfaces  have  sharply-serrated  borders,  the  inner  space  being 
grooved  and  covered  with  sharp  points,  the  whole  being  arranged  to  firmly 
grasp  a  s-tone.  The  instrument  is  usually  about  12  inches  in  length. 

Soft  Rubber  Catheters. 

A  large  soft  rubber  catheter  should  be  in  readiness  for  washing  out  fine 
fragments.  That  this  may  be  kept  free  from  coagula,  clots,  etc.,  it  should 
be  provided  with  a  stylet  by  means  of  which  the  passage  may  be  kept  free. 
It  may  be  operated  by  any  form  of  syringe,  the  fountain  syringe  being  pre- 
ferred. They  are  described  on  page  541. 

Supra-pubic  Drainage  Tubes. 

These  must  be  of  such  design  that  they  may  remain  enclosed  within  the 
incision,  forming  means  for  continuous  drainage. 

Keith's  Supra-pubic  Drainage  Tube,  as  shown  by  figure  1304,  consists  of 
a  hard  rubber  base,  to  which  is  attached  the  tip  of  a  soft  rubber  catheter  of 
large  size.  As  the  latter  is  elastic,  and  as  it  may  be  cut  to  any  length,  it 
may  be  employed  to  conduct  fluids  from  any  desired  location.  The  hard 
rubber  portion  of  the  instrument  is  curved  at  nearly  a  right  angle  and 
arranged  for  attachment  to  a  rubber  hose.  Two  collars  placed  at  about  the 
middle  of  the  rigid  portion  enable  the  operator  to  attach  the  instrument  to  a 
body  band  of  any  desired  size. 

Senn's  Supra-pubic  Drainage  Tube,  as  outlined  in  figure  1306,  consists  of 
a  slender  tube  of  sigmoid  shape,  the  vesical  end  terminating  in  a  slender 
bulb  that  tapers  toward  both  ends,  somewhat  in  barrel  form.  The  latter 
is  usually  about  -^6  of  an  inch  in  its  largest  diameter  and  i  inch  in  length, 
its  circumference  containing  a  large  number  of  oval  openings,  each  about  3 
millimeters  in  length  by  i^  in  width.  Three  oval  openings  are  also 


562  GENITOURINARY    SURGERY. 

provided  on  the  outer  and  lateral  aspects  of  the  tube,  just  back  of  the  bulb 
at  its  point  of  second  curvature.  The  bulb  is  also  open  at  its  extreme  end. 
A  collar  is  provided  on  the  proximal  end  for  the  attachment  of  a  rubber 


Figure  1304.     Keith's  Supra-pubic  Drainage  Tube. 


Figure  1305.    McGuire's  Plug  for  an  Artificial  Figure  1306.    Senn's  Supra-pubic  Drainage  Tube. 

Supra-pubic  Urethra. 

hose.  While  the  usual  length  of  this  tube,  including  curvatures,  is  about  4 
inches,  this  must  vary  according  to  the  thickness  of  the  walls  at  the  point 
of  insertion. 

McGuire's  Plug,  shown  by  figure  1305,  consists  of  a  silver  or  hard  rubber 
stem  mounted  upon  a  small  circular-  disc.  The  stem  should  be  slightly 
curved,  about  No.  12,  American  scale,  and  just  long  enough  to  enter  the 
bladder.  It  is  used  to  maintain  the  patency  of  an  artificial  supra-pubic 
urethra,  and  to  act  as  a  stopper  to  prevent  dribbling  of  urine.  It  is  intended 
for  constant  use,  to  be  removed  only  when  urine  is  voided. 

Avulsion  Forceps. 

These  are  required  for  the  removal  of  tumors.  They  should  be  of  such 
construction  that  there  will  be  little  danger  of  including  the  bladder-wall 
within  the  grasp  of  the  instrument.  Usually  they  may  be  guided  with  the 
finger,  and  a  tumor  dislodged  as  a  whole  or  torn  away  in  pieces. 


Figure  1307.    Thompson's  Separating  Forceps. 

Thompson's  Badder  Forceps,  as  outlined  in  figures  1307  to  1309,  are 
particularly  designed  for  grasping  pedunculated  and  sessile  growths,  either 
for  the  purpose  of  avulsion  or  to  separate  and  hold  them  for  excision.  All 
are  manufactured  with  well-rounded  parts,  free  from  sharp  angles  or  pro- 
jections. 

The  separating  forceps,  the  first  shown,  is  slender  in  form,  curving 
downward  and  outward,  the  lower  or  inner  borders  of  the  blades  being 
serrated  with  sharp  teeth.  It  is  intended  that  the  instrument  shall  present 


PERINEAL    CYSTOTOMY. 


563 


about  the  same  curve  as  the  bladder  wall,  that  the  separation  of  tumor 
masses  from  normal  tissue  may  be  the  more  easily  secured. 


Figure  1308.    Thompson's  Bayonet  Avulsion  Forceps. 

The  bayonet  pattern  does  not  differ  materially  from  the  one  just 
described  excepting  that  the  blades  are  broad,  oval  in  form,  provided  with 
fenestrae,  and  the  toothed  margins  extend  not  only  along  the  lower  but 
around  the  outer  border. 


Figure  1309.    Thompson's  Curved  Avulsion  Forceps. 

The  full-curved  pattern  differs  from  the  one  last  described  in  being 
curved  on  the  flat  to  nearly  a  right  angle.  The  surgeon  provided  with  these 
three  patterns  should  be  able  to  meet  all  indications. 

Perineal  Cystotomy  or  Lithotomy. 

This  may  be  median,  lateral,  bilateral,  medio-lateral  or  medio-bilateral. 
As  the  appliances  required  are  practically  the  same  in  each,  no  attempt  to 
formulate  separate  lists  seems  necessary.  The  instruments  required  com- 
prise the  folowing: 

Minor  operating  instruments,  described  on  page  270  or  275. 

Leg  holder,  for  separating  and  holding  legs  apart,  figures  194  to  197. 

Lithotomy  scalpel,  for  incision. 

Lithotomy  bistoury,  for  enlarging  deeper  incisions. 

Lithotomy  staff,  for  conducting  knife  into  bladder. 

Lithotomy  forceps,  for  removal  of  calculi,  figures  1298  to  1300. 

Lithotomy  scoop,  for  dislodging  and  removing  calculi,  figure  1301. 

Compression  forceps,  for  arresting  hemorrhage,  figures  938  to  944. 

Catheter  en  chemise,  or  air  tampon,  for  arresting  continued  hemorrhage 
of  vessels  not  easily  ligated. 

Large  soft  rubber  tube,  for  washing  out  debris,  figure  2148. 

Drainage  tube. 

Lithotomy  Scalpels  and  Bistouries. 

These  differ  from  ordinary  patterns  in  being  constructed  with  straight 
or  back  ward- curved  blades.  They  are  generally  preferred  to  the  ordinary 
designs,  because  in  the  latter  there  is  more  or  less  taper  to  the  back  of  the 


564 


GENITO-URINARY    SURGERY. 


blade,  and  an  instrument  so  constructed  would  be  more  likely  to  slip  from 
a  guide  or  staff  in  making  a  perineal  incision.  Generally,  they  are  of 
heavy  construction  with  blades  from  3  to  3}^  inches  in  length. 

Lithotomy  Scalpels  and  Bistouries  are  well  illustrated  by  figures  1310, 
1311  and  1312.     The  first  two  differ  from  each  other  only  in  that  one  is  probe- 


Figure  1310.    Sharp-pointed  Lithotomy  Scalpel. 


Figure  1311.    Probe-pointed  Lithotomy  Scalpel. 


Figure  1312.      Blizzard's  Probe-pointed  Lithotomy  Bistoury. 

pointed.  In  the  hands  of  an  inexperienced  operator  the  latter  instrument 
might  prove  safer,  as  the  long  probe-point  is  not  as  liable  to  be  forced  out 
of  the  staff  groove.  The  probe-pointed  bistoury  is  frequently  employed  for 
enlarging  the  primary  prostatic  incision. 

Lithotomy  Staffs. 

These  consist  of  urethral  sounds  constructed  with  a  slot  or  groove,  the 
latter  serving  to  guide  the  point  of  a  knife  through  the  prostate  and  into 
the  bladder  after  the  sound  has  been  passed  the  length  of  the  urethra. 

These  instruments  are  usually  curved  like  an  ordinary  catheter,  or  the 
curve  extended  until  the  instrument  presents  a  somewhat  hooked  form,  thus 
bulging  into  the  perineum.  The  groove  usually  extends  nearly  the  entire 
length  of  the  instrument,  and  is  located  either  upon  the  outer  surface  of  the 
curve  or  upon  one  side.  Lateral  grooves  are  preferred  by  some  operators, 
because  they  are  more  easily  distinguished  and  located.  The  groove  should 
occupy  from  one-fourth  to  one-third  of  the  circumference  of  the  staff,  and 
should  be  sufficiently  deep,  so  that  the  point  of  the  knife  may  be  guided  by  it 
without  danger  of  displacement.  The  points  of  many  patterns  are  bulbous, 
that  they  may  be  used  in  searching  for  stone.  The  size  employed  for  the 
male  is  usually  about  No.  12,  and  that  for  children  about  No.  8,  American 
scale. 


Figure  1313.    Plain  Lithotomy  Staff. 


A  Plain  Lithotomy  Staff,  as  shown  by  figure  1313,  consists  of  a  flattened 
handle,  with  a  shaft  about  1 2  inches  in  length,  fully  one-half  of  which  is 
included  in  a  large  sweeping  circle  provided  upon  its  outer  margin  with  a 
groove  that  includes  about  one-third  of  the  staff  circumference. 


PER1NEAL    CYSTOTOMY. 


565 


Little's  Lithotomy  Staff,  as  exhibited  by  figure  1314,  differs  from  the  one 
last  described  in  being  only  about  10  inches  in  length,  exclusive  of  the 
handle,  and  provided  with  a  wider  groove  and  a  small  bulbous  tip. 


Figure  1314.    Little's  Lithotomy  Staff. 


Mar koe's  Lithotomy  Staff,  as  shown  in  figure  1315,  is  still  shorter  than  the 
one  last  above  described,  being  only  8  inches  in  length,  exclusive  of  the 
handle.  Fully  two-fifths  of  this  instrument  is  given  up  to  the  groove,  so  that 


the  latter  is  wide  and  shallow.     The  instrument  is  slightly  more  than  half 
curved,  and  constructed  with  a  bulbous  tip. 

Buchanan's  Rectangular  Staff,  as  illustrated  by  figure  1316,  consists  of  a 


Figure  1316.    Buchanan's  Rectangular  Staff. 

slender  shaft  about  1034  inches  in  length,  2^  inches  of  which  is  bent  at  a 
right  angle  with  the  main  portion.  This  terminal  section  is  provided  with 
a  deep  groove  upon  its  outer  surface.  The  tip  is  slightly  curved  backward, 
the  better  to  facilitate  its  passage.  It  is  employed  in  median  lithotomy  to 
bring  the  apex  of  the  prostate  nearer  to  the  perineal  surface. 

Perineal  Drainage  Tubes. 

These   are   intended   to   secure   complete   bladder  drainage,  following 
perineal  cystotomy. 


Figure  1317.    Morrow's  Perineal  Drainage  Tube.     Figure  1318.    Morrow's  Chemise  Drainage  Tube. 


Morrow's  Perineal  Drainage  Tube,  as  it  appears  in  figure  1317,  consists 
of  a  thin,    hard   rubber   tube   of  large  caliber,  curved  so  as  to  rest  just 


566 


GENITOURINARY    SURGERY. 


within  the  lower  portion  of  the  bladder,  when  the  patient  is  lying  on 
the  back.  That  it  may  be  adjusted  to  different  thicknesses  of  intervening 
tissue — that  is,  between  the  outer  perineal  margin  and  the  bladder-open- 
ing— it  is  provided  with  an  adjustable  sliding  collar.  This  collar  is  provided 
with  means  for  attaching  tapes,  so  that  the  whole  may  be  firmly  held  in 
position.  The  ridge  shown  in  the  tube  near  the  vesical  end  is  for  the  pur- 
pose of  constructing  a  tube  en.  chemise. 

Drainage  Tubes  en  Chemise  are  sometimes  employed  to  control  venous 
hemorrhage  in  a  perineal  incision.  They  consist  of  tubes  of  the  proper 
length  surrounded  by  gauze  in  the  form  of  a  skirt.  They  may  be  prepared 
by  passing  the  tube  through  a  small  hole  in  the  center  of  a  six-inch  square 
of  gauze,  and  tying  the  cloth  in  place  below  the  tip.  After  passing  the 
tube  into  the  bladder,  the  space  surrounding  the  tube  and  between  it  and 
the  cloth  may  be  packed  with  antiseptic  gauze,  the  latter  crowded  in  until 
the  hemorrhage  is  controlled  by  pressure.  Soft  rubber  catheters  or  special 
tubes  may  be  employed. 

Morrow's  Chemise  Drainage  Tube,  as  set  forth  in  figure  1318,  is  of 
metal  with  a  rounded  vesical  end,  lateral  catheter  openings,  and  wings  on 
the  proximal  end  to  assist  in  its  manipulation.  Two  rings,  situated  about 
one-quarter  of  an  inch  apart,  encircle  the  tube  just  back  of  the  eyes,  and 
between  these  riDgs  the  cloth  may  be  bound. 


Figure  1319.    Buckston  Brown's  Soft  Rubber  Tampon. 


Figure  1320.    Plain  Metal  Chemise 
Drainage  Tube. 


Buckston  Brown's  Soft  Rubber  Tampon,  as  displayed  by  figure  1319, 
consists  of  a  catheter  surrounded  with  a  collapsible  rubber  bag,  the  latter 
capable,  after  introduction,  of  being  inflated  with  air  or  water,  the  latter 
preferred.  By  this  means  the  catheter  may  not  only  be  held  in  place  but 
sufficient  pressure  may  be  produced  on  the  surrounding  parts  to  control 
hemorrhage. 

The  Plain  Metal  Chemise  Drainage  Tube,  as  outlined  in  figure  1320, 
consists  of  a  metallic  cylinder  about  4  or  5  inches  in  length,  the  distal  end 
of  which  is  closed  and  provided  with  small  lateral  openings  that  permit  the 
escape  of  fluids.  The  proximal  end  is  supplied  with  perforations,  that  it 
may  be  secured  by  suitable  tapes.  The  outer  surface  may  be  roughened 
or  provided  with  small  rings  encircling  the  stem  to  serve  as  means  for 
preventing  the  fabric  compress  from  slipping  along  the  tube,  during  or 
after  insertion. 


SURGERY    OF    THE    URETHRA. 


567 


SURGERY  OF  THE  URETHRA. 

The  instruments  required  in  urethral  surgery  may  be  classified  as  fol- 
lows: Those  for  making  examinations,  treatment  of  stricture,  application 
of  remedies  or  dressings  and  removal  of  foreign  bodies. 


2  Q 


O-  O  a 

^X-N       -    ^-\      „ 

~vJ      {)  • 


o*« 


<*  o  n  ra 


«  o  as 


%- 


o  o/ 


O 


^o 


oof 


.CD    - 


«c>   - 


Figure  1321.    Showing  Approximate  Sizes  of  Gauges  or  Scales. 

Instruments  introduced  into  the  urethra  should  be  carefully  sterilized 
before  use.     Where  lubricants  are  employed,  they,  too,  should  be  aseptic. 


568  GENITOURINARY    SURGERY. 

Metallic  instruments,  such  as  sounds,  should  be  warmed  to  about  the 
temperature  of  the  body  before  introduction. 

As  urethral  instruments  are  usually  selected  according  to  some  scale  of 
measurement,  it  is,  perhaps,  well  to  show  a  comparison  of  the  systems  in 
common  use.  The  English,  French  and  American  systems  are  confusing, 
and  we  question  the  necessity  for  formulating  the  last  devised,  the  Amer- 
ican. The  English,  for  some  time  the  best  known,  is  practically  worthless, 
for  there  are  only  a  few  sizes  or  numbers,  and  there  appears  to  be  no  reg- 
ular standard  for  the  sizes.  They  not  only  vary  with  different  authorities 
and  makers  of  instruments,  but  the  variations  from  one  size  to  another  are 
without  regularity. 

The  French  system  advances  systematically  by  thirds  of  millimeters. 
and  seems  to  furnish  all  that  is  necessary  in  the  way  of  graduation.  The 
American  system,  strangely  enough,  is  based  on  the  French  scale  of  meas- 
urement and  differs  only  in  advancing  by  halves  of  millimeters.  With  a 
millimeter  scale,  or  a  pair  of  carefully-graduated  calipers,  the  physician  may 
determine  the  correct  number  of  any  instrument.  The  French  number 
may  be  found  by  multiplying  the  diameter  in  millimeters,  by  three ;  the 
American  number  by  multiplying  the  same  diameter  by  two.  For  the 
purpose  of  rapid  determination  and  finding  a  corresponding  equivalent,  we 
append  the  comparative  scale  of  the  three  systems  in  use,  giving,  in  the 
first  column,  the  diameters  in  millimeters  and  fractions  thereof. 

Comparison  of  Scales  or  Gauges. 


Diameters  in 
Millimeters. 

American 
Gauge. 

French 
Gauge. 

English 
Gauge. 

/3  

—  

I  



YI 

I  

— 



/3  

—  

-7 



I  

2  

3  



1/3  



4  



ll/2  

3  

—  



1/3  

—  

5  



2  

4  

6  



2/3  

—  

7  

1 

2/2  

5  

—  



2/3  

—  

8  

2 

3  

6  

.   o  .  . 

-> 

3/3  

JO  

3^  

7  

—  

:  — 

3/3  

—  

ii  

4 

4  

8  

12  ... 

c 

4/3  

13  

o 

4^  

9  





42/3  

—  

14  



c  .  . 

10  

j  r 

6 

5/3  

16  

7 

5/2  

ii  

—  

— 

5/3  

—  

17  

8 

6  

12  

18. 

6/3  

19  

10 

6/2  

13  

—  .  .  . 

— 

6/3  



20  

ii 

7  

14  

21  

.  .— 

URETHRAL    GAUGES    AND    SCALES. 


Diameters  in 

American 

French 

English 

Millimeters. 

Gauge. 

Gauge. 

Gauge. 

7/3  



22  

12 

7  1^  

15  





7/3  



23  

'3 

8  

16  

24  



S/3  

—  

25  

14 

8^3  

_i 

26  

15 

9  

18  

27  

16 

9/3  

—  

28  

17 

91A  

19  



— 

9^3  

—  

29  

— 

10  

20  

30  

18 

i  o  T/i  

—  

31  

19 

io*/2  

21  

—  

— 

io^i  



32  

20 

ii  

22  

33  

21 

n#  

.  .  

34  

22 

ii  }4  

23  

—  



n^  



35  

23 

12  

24  

36  

24 

I2l/J,  



37  

25 

12  ^  

25  

—  



12^/3  



38  

26 

13  

26  

39  

27 

13/3  



4o  

28 

Urethral  Instrument  Gauges. 

A  scale  or  measure  by  means  of  which  the  physician  may  determine  the 
size  of  an  instrument  or  the  correctness  of  a  number  will  often  be  found  of 


DR. C.H.THOMAS' 
ADAPTABLE  METRIC  GAUGE. 

GEORGE  TIEMANN&CO. 


Figure  1322.     Thomas'  Urethral  Instrument  Gauge. 

convenience.     Pasteboard  scales,  perforated  in  accordance  with  the  Amer- 
ican and  French  numbers,  are  distributed  gratis  by  most  dealers  in  surgical 

supplies. 


AMERICAN. 


F Ft  E  A/  C  H. 


Figure  1333.     Handerson's  Urethral  Instrument  Gauge. 

Thomas'  Gauge,  as  described  by  figure  1322,  consists  of  a  wooden  han- 
dle or  shaft,  to  one  end  of  which  a  graduated  tape  is  looped  in  such  a  man- 
ner that  the  size  of  the  loop  opening  may  be  varied  as  desired.  The  tape  is 


570 


GENITOURINARY    SURGERY. 


graduated  so  as  to  show  the  American  scale  of  any  instrument  placed  within 
the  tightly-drawn  loop. 

Hander son's  Gauge,  as  clearly  shown  in  figure  1323,  is  an  oblong  metallic 
plate,  preferably  of  steel,  in  the  center  of  which  is  a  right-angled  triangular 
opening,  about  15  millimeters  wide  at  its  base,  and  decreasing  regularly 
towardj  the  apex.  The  margins  are  graduated,  and  correspond  one  with 
the  American,  the  other  with  the  French  scale.  With  this  gauge,  the  sizes 
of  small  instruments  may  be  correctly  and  quickly  determined. 

Examinations. 

The  instruments  generally  required  for  examinations  are ; 

Syringe  for  local  anesthesia. 

Bougies  for  tactile  examinations. 

Endoscopes,  or  specula,  for  ocular  examinations. 

Light  and  mirrors  for  illumination. 

Swabs  for  wiping  away  mucous  discharges. 

Probes  for  examinations  of  growths,  sinuses,  etc. 

Urethrometer  for  determining  extent  of  stricture. 

Syringes  for  Local  Anesthesia. 

Usually,  these  consist  of  a  slender  pipe  or  tube,  with  some  form  of 
syringe,  generally  of  hypodermic  pattern. 


Figure  1384.    Brown's  Cocainizing  Syringe. 

Brown's  Cocainizing  Syringe,  as  illustrated  by  figure  1324,  consists  of 
a  delicate  silver  tube,  bent  in  such  a  manner  that  the  handle  or  syringe 
barrel  is  below  or  to  one  side  of  the  field  of  vision.  The  tip,  or  pipe,  is  of 
soft  or  pure  silver,  that  it  may  be  curved  in  any  desired  form.  It  may  also 
be  used  for  injections  of  hydrogen  peroxide,  etc. 


.T«IJ*X  GREENE-LO.' 


Figure  1325.    Wyeth's  Cocainizing  Syringe  Pipe. 

Wyeth's  Cocainizing  Syringe  Pipe,  as  shown  by  figure  1325,  consists  of 
a  slender  rigid  tube  that  may  be  connected  with  almost  any  form  of  hypo- 
dermic syringe.  The  tube  is  slightly  curved  at  the  tip,  the  fluid  being 
forced  through  a  number  of  fine  openings  in  the  circumference  of  the  pipe. 
By  means  of  this  tube,  a  thorough  application  may  be  made  to  the  urethra. 

Urethral  Bougies. 

These  consist  of  slender  elastic  instruments,  usually  in  cylindrical  rod- 
like  form,  employed  in  tactile  examinations  to  explore,  dilate  or  maintain 


URETHRAL    BOUGIES. 


571 


the  patency  of  the  urethral  canal.  With  few  exceptions,  they  are  made  of 
woven  fabric  in  the  same  manner  and  on  the  same  machines  as  catheters. 
As  the  construction  of  the  latter  has  been  fully  described  in  this  chapter, 
no  further  mention  is  necessary. 

Generally  bougies  are  of  silk,  linen  or  cotton;  the  latter,  owing  to  its 
coarseness  of  fiber,  being  employed  only  in  the  cheaper  grades.  They  are 
woven  over  a  mandrel  or  iron  rod,  similarly  to  the  threads  that  cover  a 
horsewhip,  after  which  they  are  coated  with  varnish  or  other  similar 
material,  thus  furnishing  soft,  elastic  instruments.  They  may  be  classified 
according  to  shape,  the  more  common  being  cylindrical,  conical,  olive-tip, 
bellied,  a-boule  and  filiform. 

Cylindrical  Bougies  are  those  of  the  ordinary  form  with  plain,  straight 
shaft  and  rounded  vesical  ends.  Usually,  they  may  be  procured  in  linen  or 
cotton,  the  latter  forming  the  old-fashioned  English  bougies. 


Figure  1326.    Cylindrical  Bougie. 

Cylindrical  Bougies,  as  shown  in  figure  1326,  may  be  obtained  of  any 
number  of  the  American  scale,  from  i  to  20,  inclusive. 

Conical  Bougies  differ  from  the  cylindrical  pattern  in  being  constructed 
with  a  tapering  or  conical  point. 


Figure  1327.    Conical  Bougie. 

Conical  Bougies,  as  exhibited  in  figure  1327,  are  usually  made  from 
linen.  This  variety  does  not  command  a  large  sale,  and  hence  can  not  be 
purchased  either  in  as  many  numbers  or  qualities  of  material. 

Olive-tip  Bougies  are  constructed  with  a  bulbous  tip  attached  to  the 
main  body  or  shaft  by  a  slender  neck.  This  form  furnishes  an  elastic  point 
that  more  easily  follows  a  tortuous  canal.  As  this  pattern  is  quite  popular, 
it  may  be  found  in  a  great  variety  of  qualities.  Many  have  been  placed 
on  the  market  that  are  wholly  unfit  for  use.  By  reason  of  cheap  construc- 
tion, they  are  either  too  rigid,  fragile  or  improperly  coated.  Those  made 
from  linen  are  usually  preferred,  provided  they  are  coated  in  a  first-class 
manner. 


Figure  1328.    Olive-tip  Bougie. 

Olive-tip  Bougies,  as  set  forth  in  figure  1328,  may  usually  be  obtained 
in  a  greater  variety  of  sizes  than  other  forms.  This  is  particularly  true 
where  extra  large  sizes  are  desired. 


Figure  1329.    Bellied  Bougie. 


The  Bellied  Bougie,  as  portrayed  by  figure  1329,  is  constructed  with  a 
long  and  slender  olive-shaped  enlargement  near  its  distal  end.  It  serves 
as  a  dilator,  in  passing  both  in  and  out  of  the  urethra. 


572 


GENITOURINARY    SURGERY. 


Bougies-a-Boule  usually  consist  of  acorn-shaped  bulbs  mounted  upon 
the  end  of  slender  wire-like  rods.  They  are  employed  for  locating-  and 
determining  the  internal  diameter  of  a  stricture  together  with  its  extent. 
The  form  most  preferred  is  one  where  the  shoulder  or  proximal  border  of 
the  bulb  joins  the  stem  at  nearly  a  right  angle.  Occasionally,  they  are 
employed  in  patterns  where  two  or  more  bulbs,  separated  an  inch  or  more 
apart,  are ,  mounted  on  a  single  stem.  They  are  manufactured  both  of 
elastic  web  and  metal,  the  latter  being  usually  preferred. 

Great  care  should  be  exercised  in  the  manufacture  of  these  instruments, 
and  surgeons  should  purchase  only  those  of  known  reliability,  as  many 
accidents  have  occurred  by  the  separation  of  the  bulb  from  the  shaft. 
This  caution  applies  to  both  the  elastic  web  and  the  metal  bougies,  the  former 
breaking  because  the  bulb  is  made  separately  and  covered  with  only  a  por- 
tion of  the  woven  threads,  while  the  latter  become  separated  on  account  of 
improper  soldering.  All  should  be  tested  before  use,  to  see  that  the  bulbs 
are  firm  and  strongly  united  to  the  shaft. 


Figure  1330.    Elastic  Web  Bougie-a-Boule. 

The  Bougie-a-Boule,  as  traced  in  figure  1330,  when  properly  constructed, 
furnishes  a  desirable  instrument.  It  is  not  so  largely  employed  as  the 
all-metal  pattern  described  in  the  following  illustration.  It  may  be  pro- 
cured in  almost  any  number  of  the  French  scale. 


TRUAX,  GREENE  &  Co. 
Figure  1331.     Otis'  Metallic  Bougie-a-Boule. 

Otis'  Bougie-a-Boule,  as  exhibited  by  figure  1331,  consists  of  acorn- 
shaped  bulbs  attached  to  slender  wire-like  rods  or  shanks,  the  latter,  at  their 
distal  end,  terminating  in  small,  disc-like  handles,  upon  which  the  num- 
ber of  the  French  scale  is  stamped.  These  may  be  obtained  in  any  size 
from  about  5  to  40.  Many  surgeons  who  do  not  wish  to  invest  in  a  complete 
set  obtain  them  in  alternate  numbers,  claiming  that  such  an  assortment 
answers  every  purpose. 


•  Figure  1332.     Fowler's  Modification  of  Otis'  Bougie-a-Boule. 

Fowler's  Modification  of  Otis'  Bougie,  as  represented  by  figure  1332, 
consists  of  a  rod,  each  end  of  which  terminates  in  a  bulb,  numbered  from 
10  to  40.  Each  pair  of  bulbs  is  provided  with  a  slide  and  set  screw, 
adjusted  to  fit  the  shank,  upon  which  is  stamped  the  number  of  the  instru- 
ment. When  in  use,  the  slide  may  be  moved  to  the  end  opposite  the  bulb 
to  be  inserted.  The  location  of  the  stricture  may,  if  desired,  be  accurately 
marked,  while  the  bulb  is  engaged  in  the  stricture,  and  securing  it  with  the 
set  screw,  by  passing  the  slide  along  to  the  meatus. 


URETHRAL    BOUGIES. 


573 


Filiform  Bougies  consist  of  thread-like  rods,  employed  to  locate  minute 
strictural  openings,  as  directors  for  the  introduction  of  larger  instruments, 
and  in  certain  cases  to  maintain  the  patency  of  the  canal.  In  some  cases 
where  a  catheter  can  not  be  passed,  several  filiform  bougies  may  be  intro- 
duced into  the  bladder,  side  by  side,  when,  if  allowed  to  remain,  the  urine 
may  escape  by  constant  dribbling.  In  some  cases  where  a  single  one 
can  not  be  passed  and  the  stricture  presents  a  somewhat  bold  proximal  wall, 
several  may  be  introduced  until  all  rest  against  the  obstructing  mass,  when 
each  may  be  tried  in  turn  with  the  hope  of  finding  one  that  will  enter  the 
opening.  They  are  manufactured  from  whalebone,  woven  fabric,  catgut 
or  silkworm  gut. 

Whalebone  Filiform  Bougies  are  more  largely  employed  than  any  other 
variety.  This  is  owing  to  the  elasticity  and  toughness  of  this  material. 
Instruments  of  fine  caliber  may  be  employed  with  comparative  safety. 
They  are  not  only  generally  used  for  explorative  purposes,  but  as  guides 
for  the  introduction  of  tunneled  or  grooved  instruments.  They  are  also 
employed  in  small  sizes  for  dilators,  and  occasionally  several  are  used  for 
catheterism,  as  before  mentioned.  Owing  to  the  high  cost  of  the  material 
their  use  is  generally  restricted  to  small  sizes.  They  are  usually  either 
cylindrical  or  olive-tipped.  Corkscrew  and  angular  patterns  may  be 
formed  by  curving  either  of  the  above-mentioned  varieties  over  the  finger- 
nail, although  much  better  ones  can  be  purchased  from  the  dealer  in  the 
forms  and  shapes  required. 


Figure  1333A.    Whalebone  Filiform  Bougies. 

Whalebone  Filiform  Bougies,  as  displayed  in  figure  1332  A,  show  the  ordi- 
nary forms  of  the  olive-tip  and  cylindrical  varieties.  They  may  be  pro- 
cured in  assorted  sizes  and  shapes.  They  should  be  stored  in  slender  tin 
cases,  as  above-illustrated. 


TRUAX,  GREENE  &  Co. 


Figure  1333.    Goulay's  Whalebone  Filiform  Bougies  or  Guides. 

Goulay's  Whalebone  Filiform  Bougie,  as  indicated  by  figure  1333,  differs 
from  the  ordinary  patterns  above  described  only  in  being  curved  and  gen- 


Figure  1334.    Banks'  Whalebone  Filiform  Bougies. 


erally  of  extra  length.  The  angular  and  corkscrew  curves  will  retain  their 
forms  longer  when  prepared  by  the  dealer.  Extra  lengths  of  20  to  24  inches 
are  frequently  required  when  used  as  guides. 


574  GENltO-URINARY    SURGERY. 

Banks'  Filiform  Bougies  consist  of  rod-like  shafts  terminating  in  slender 
bulbous  tips.  That  portion  of  each  that  lies  between  the  cylindrical  body 
and  the  small  or  filiform  portion  presents  a  conical  oval  form  that  grad- 
ually decreases  in  diameter,  so  that  the  instrument  from  a  fine  and  slender 
neck  presents  an  oval  wedge-like  form,  thus  securing  the  greatest  advantage 
in  strictural  dilatation.  As  disclosed  by  figure  1334,  they  are  usually  in  three 
sizes,  known  as  Nos.  7,  9  and  n,  French  scale. 


Figure  1335.    Hunter's  Filiform  Bougie. 

Hunter's  Filiform  Bougie  differs  from  the  pattern  of  Banks,  in  that  the 
shaft  and  filiform  portions  are  round.  The  tip  may  be  either  straight,  bent 
at  an  angle,  or  in  corkscrew  form.  They  are  constructed  with  a  small 
bulbous  end,  back  of  which  the  slender  neck  gradually  increases  in  size,  until 
at  the  junction  of  the  outer  and  middle  thirds  the  instrument  is  increased 
to  the  full  diameter  of  the  shaft.  They  are  well  shown  by  figure  1335. 

Woven  Fabric  Filiform  Bougies  are  manufactured  in  the  same  manner 
as  catheters,  as  described  by  figures  1255  to  1261.  They  are  made  from  silk 
or  fine  linen,  the  former  being  preferred  because  it  possesses  greater 
strength  and  more  elasticity.  Usually  the  tips  are  cylindrical,  for,  owing  to 
their  minute  size,  it  is  difficult  to  construct  them  in  any  other  form. 


Figure  1336.    Woven  Fabric  Filiform  Bougies. 

Woven  Fabric  Filiform  Bougies,  as  they  appear  in  figure  1336,  may  be 
procured  in  sizes  ranging  from  Nos.  i  to  6,  French  scale.  As  they  are 
of  delicate  construction,  they  should  be  well  cared  for,  and  riot  curved  at 
sharp  angles  unless  absolutely  necessary. 

Catgut  Filiform  Bougies  consist  of  strands  of  catgut  finished  with  round 
cylindrical  ends.  They  are  not  much  employed  because  they  become  soft 
by  the  absorption  of  fluids. 

Silkworm  Gut  Filiform  Bougies  are  sometimes  used  where  very  fine  ones 
are  necessary.  They  may  be  constructed  from  an  extra  fine  quality  of  silk- 
worm gut  by  smoothing  and  rounding  the  ends  with  fine  emery  paper. 

Endoscopes. 

Endoscopes,  or  specula,  are  required  for  ocular  examination  of  the  male 
urethra,  particularly  for  parts  deeper  than  the  glans  penis. 

Endoscopes  consist  of  tubes  of  such  diameters  and  lengths  that  they  may 
be  passed  into  the  urethra,  thus  admitting  light  while  distending  the  folds 
into  an  open  canal.  In  cases  of  stricture  they  may  be  passed  down  until  they 
rest  against  its  anterior  surface,  where  they  furnish  a  good  view  of  the 
thickened  structures,  and  may  thus  assist  in  discovering-  an  obscure  open- 
ing. 

Originally,  endoscopes  were  manufactured  with  funnel-shaped  visual 
ends,  as  it  was  the  belief  that  by  this  form  the  amount  of  illumination  might 
be  increased.  Experience  proved  that  practically  only  such  rays  as  were 
parallel  to  the  lumen  of  the  tube  passed  to  or  from  its  lower  border,  and  that 
as  a  consequence  this  shape  was  unnecessary.  The  surgeon,  in  his  efforts  to 
pass  the  tube  further  into  the  canal,  frequently  forced  the  funnel  portion 


URETHRAL    ENDOSCOPES. 


575 


through  the  meatus  far  enough  to  produce  much  pain  and  discomfort. 
Instead  of  the  older  pattern,  straight  tubes  with  discs  at  their  ocular  ends 
are  now  almost  universally  employed,  the  discs  serving  as  handles  and  to 
prevent  the  tube  from  being  introduced  too  far.  They  may  be  of  silver  or 
other  thin  metal.  The  former  admits  of  the  use  of  caustics  or  astringents 
without  damage  to  the  instrument.  Hard  rubber  is  objectionable,  because 
it  requires  a  tube  with  a  thicker  wall,  and  in  tubes  of  such  length  many 
light  rays  are  absorbed  by  the  dark  surface,  thus  furnishing  an  imperfect 
illumination.  Glass  has  been  employed  for  these  instruments,  but  the  dan- 
ger of  breakage  while  in  situ  renders  it  objectionable.  The  size  selected 
for  a  given  case  should  be  the  largest  that  can  be  passed  through  the 
meatus  and  the  shortest  that  will  illuminate  the  desired  field,  those  under 
No.  23,  French  scale,  being  seldom  employed. 


Figure  1337.     Klotz's  Endoscope. 

Klotz's  Endoscope,  as  manifest  in  figure  1337,  consists  of  metallic  tubes  of 
various  lengths,  as  above  described.  In  general  form,  the  instrument  com- 
prises a  straight  tube  open  at  both  ends,  to  one  of  which  a  flat  metal  disc 
about  2  inches  in  diameter  is  attached.  The  outer,  or  ocular,  side  of  this 
disc  is  covered  with  a  plate  of  hard  rubber,  to  avoid  the  dazzling  reflection 
that  would  be  caused  by  a  metallic  surface.  Each  instrument  is  provided 
with  a  small  obturator  with  suitable  handle  and  well-rounded  tip,  the  latter 
projecting  beyond  the  distal  end  of  the  tube  in  order  to  facilitate  its  intro- 
duction. After  the  instrument  is  in  place,  the  obturator  may  be  withdrawn. 
Klotz  recommends  the  following  set,  selected  on  the  French  scale  of 
sizes: 

One   each,  No.  23,  length  3  inches 

24, 

26, 

26, 

28,          ~s'y2 

3°,  4 

3°» 


In  addition  to  these,  tubes  6 
required. 


to  6*4   inches  in  length  are  occasionally 


Figure  1338.    Otis'  Endoscope. 


Otis'  Endoscope,  as  shown  in  figure  1338,  consists  of  a  slender  tube,  the 
proximal  end  of  which  is  funnel-shaped.  It  is  provided  with  an  obturator 
controlled  by  an  external  handle.  The  vesical  end  of  the  tube  is  turned 
in  to  fit  closely  round  the  point  of  the  obturator,  that  it  may  present  a  smooth 
appearance.  Like  the  pattern  of  Klotz,  previously  referred  to,  they  may  be 
obtained  of  any  desired  size.  The  better  patterns  are  constructed  of  metal 
with  thin  walls. 


576 


GENITOURINARY    SURGERY. 


Lydston's  Urethroscope,  as  illustrated  in  figure  1339,  differs  from  the 
pattern  of  Otis  in  being-  slightly  curved  and  somewhat  conical  at  the  tip.  A 
long  oval  opening  upon  the  outer  surface  of  the  curve  admits  the  urethral 


Figure  1339.    Lydston's  Urethroscope. 

wall  at  the  point  of  examination.  It  is  provided  with  a  hard  rubber  obtu- 
rator, beveled  upon  one  side  at  its  distal  end,  that  it  may  fill  in  the  defect 
caused  by  the  fenestra  and  give  to  the  instrument  its  full  diameter  at  this 
point.  While  they  may  be  manufactured  of  any  size,  that  advised  by  its 
author  is  No.  20,  American  scale,  with  a  total  length  of  about  7  inches. 


Figure  1340.    Otis'  Electro-Urethroscope. 

Otis'  Urethroscope,  as  illustrated  by  figure  1340,  is  made  up  of  a  small 
electric  lamp  in  a  cylinder  i  inch  in  diameter  and  il/2  inches  long,  provided 
with  a  convex  lens  of  such  focus  as  to  throw  the  projecting  rays  within  the 
lumen  of  an  attached  endoscopic  tube.  A  metallic  extension  on  the  lower 
side  contains  the  conductors  and  base  of  the  lamp  and  serves  as  a  handle. 
This  portion  may  also  contain  a  cut-off,  if  one  be  desired.  A  metallic  con- 
necting bar  serves  to  unite  the  lamp  with  a  Klotz  endoscope.  This  should 
be  so  adjusted  that  the  rays  of  light  are  projected  directly  into  the  tube  of 
the  instrument.  The  attachment  to  the  endoscopic  disc  is  such  as  to  admit 
a  swinging  motion  and  to  permit  the  electric  lamp  to  be  removed  or  attached 
at  will.  The  instrument  is  light,  simple  and  inexpensive. 

Specula. 

These  are  necessarily  slender,  and  if  other  than  tubular,  of  delicate  con- 
struction, for  they  can  occupy  but  little  space  within  the  canal.  In  most 
cases,  they  are  designed  with  some  form  of  fenestra  or  its  equivalent,  that 
the  wall  of  the  urethra  may  be  inspected. 

Brown's  Wire  Speculum,  as  shown  by  figure  1341,  is  of  the  bi-valve  pat- 
tern, each  blade  consisting  of  two  somewhat  heavy  wires  converging  slightly 
at  their  distal  ends,  each  terminating  in  a  solid  portion,  so  shaped  that  when 
the  blades  are  pressed  together,  they  form  a  neat  conical  tip.  Each  blade, 
at  its  proximal  end,  is  attached  to  an  arm  projecting  at  right  angles,  the 


URETHRAL    SPECULA. 


577 


two  hinged  and  provided  with  a  set  screw  by  means  of  which  they  may  be 
spread  to  any  desired  width. 

Separation  of  the  distal  ends  of  the  blades  is  secured  by  a  lever  obliquely 
placed  and  controlled  by  a  rod  and  nut  attached  to  the  base  of  the  specu- 


Figure  1341.    Brown's  Wire  Speculum. 

lum.  This  lever  is  attached  by  a  hinged  joint  to  one  of  the  blades,  its 
opposite  end  fitting  in  a  slot  attached  to  the  controlling  rod  above  referred 
to.  By  this  ingenious  mechanism  the  blades  may  be  dilated,  at  either  end, 
independently  or  concurrently. 


Figure  1342.    Smith's  Wire  Speculum. 

Smith's  Wire  Speculum,  as  set  forth  in  figure  1342,  consists  of  four 
wire  blades,  in  pairs,  all  united  at  their  distal  ends  in  a  small  bulbous 
point.  The  two  blades  forming  the  upper  and  anterior  sides  of  the  instru- 
ment are  bent  at  their  proximal  ends  at  right  angles,  their  tips  being 
united  by  a  hinged  joint.  A  thread  screw  passes  through  this  joint.  Upon 
the  end  of  this  a  toggle  joint  is  arranged,  by  means  of  which  the  anterior 
blades  are  caused  to  separate  or  diverge.  The  two  posterior,  or  under 
blades,  are  also  bent  at  right  angles,  and  attached  to  the  toggle  joint  above 
referred  to.  All  four  of  the  blades  are  bent  outward,  the  whole  having  a 
bulbous  form  similar  in  outward  appearance  to  the  bellied  bougie  shown  in 
figure  1329.  By  turning  the  screw  any  desired  amount  of  dilatation 
may  be  obtained.  The  blades  are  about  2^  inches  in  length. 

Illumination.  • 

The  Light  employed  for  urethral  examinations  should  be  artificial, 
many  forms  of  which  will  be  found  described  by  figures  1446  to  1459. 

Reflectors  will  be  fully  described  by  figures  1460  to  1466.  For 
endosocopy,  a  mirror  with  a  10  or  1 2-inch  focus  is  to  be  preferred. 

Intra-Urethral   Mirrors. 

Intra-Urethral  Mirrors,  for  use  with  specula,  will  be  found  useful  in 
determining  the  nature  and  extent  of  abnormal  conditions  in  the  anterior 
urethra.  They  usually  consist  of  small  reflecting  surfaces  of  steel,  the 
latter  being  highly  polished  and  plated.  They  are  mounted  on  slender  wire 
handles,  the  mirror  surface  being  bent  at  an  angle  of  45°. 


578 


GENITO-URINARY    SURGERY. 


Brown's  Intra-Urethral  Mirror,  as  illustrated  in  figure  1343,  consists  of 
a  small  mirror  attached  to  a  slender  handle,  as  shown  in  the  illustration. 


Figure  1343.    Brown's  Intra-Urethral  Mirror. 

The  handle  is  so  arranged  that  it  may  be  secured  at  any  point  along  the 
shaft. 

Urethral  Swabs. 


Figure  1344.    Urethral  Swab. 

These  are  frequently  required  when  making  examinations  with  the 
speculum.  They  are  particularly  useful  in  treating  ulcers,  removing 
secretions,  etc.  They  usually  consist  of  a  slender  rod  arranged  for  holding 
a  small  cotton  mass. 

Swabs,  for  Use  in  the  Male  Urethra,  as  designated  in  figure  1344, 
usually  consist  of  a  slender  copper  rod,  about  7  inches  in  length,  similar  in 
construction  to  those  used  in  the  throat  and  anterior  nares.  They  should 
be  quite  slender  in  order  not  to  obstruct  the  view  of  the  parts. 

Probes. 

Probes,  for  urethral  use  may  be  of  any  slender  pattern,  provided  they 
are  of  proper  length.  They  are  employed  for  the  examination  of  ulcers, 
sinuses,  to  determine  the  nature  of  growths,  extent  of  lesions,  etc.  The 
uterine  probe  of  Sims,  as  seen  in  figure  1018,  will  be  found  serviceable. 


Figure  1345.    Brown's  Urethral  Probe  or  Digit. 

Brown's  Urethral  Probe  or  Digit,  as  imaged  in  figure  1345,  consists  of 
two  slender  steel  rods,  placed  parallel,  one  against  the  other.  Each  is  at- 
tached at  its  proximal  end  to  opposite  ends  of  a  U-shaped  handle  in  spring 
form,  the  movement  of  which  is  controlled  by  a  stop  and  screw  power. 
The  distal  ends  are  each  attached  to  a  short,  stiff,  rigid  finger,  or  digit,  in 


URETHROMETERS.  579 

such  a  manner  that  compression  of  the  spring  or  loop  causes  the  arm  to 
swing  until  brought  to  any  desired  angle  with  the  long  shaft  of  the  instru- 
ment. By  this  arrangement  the  finger  may  be  projected  at  a  right  angle 
to  the  shaft  of  the  instrument.  It  is  particularly  useful  in  making  examina- 
tions, and  may  in  some  cases  be  used  to  advantage  in  the  extraction  of  for- 
eign bodies. 

Urethrometers. 

These  consist  of  a  shaft,  terminating  in  an  expanding  bulb,  controlled 
by  screw  power,  the  amount  of  dilatation  being  registered  by  an  accurate 
dial.  Before  being  expanded  they  should  be  introduced  as  far  as  the  bulb- 
ous urethra,  when  they  may  be  dilated  to  the  size  of  Nos.  22  to  24, 
French  scale,  and  gently  drawn  toward  the  meatus.  If  brought  into  con- 
tact with  a  stricture,  and  the  bulb  fails  to  pass,  by  gradually  reducing  the 
diameter  and  making  repeated  efforts,  the  largest  size  that  will  pass  through 
the  constriction  may  be  determined. 


Figure  1346.    Otis'  Urethrometer. 


Otis'  Urethrometer,  as  portrayed  by  figure  1346,  is  a  tubular  shaft, 
about  7^  inches  in  length,  marked  in  graduations  of  i  inch  each.  Five 
jointed  arms  are  attached  to  the  vesical  end  of  the  shaft.  A  central  rod 
passing  through  the  shaft  connects  with  a  tip,  to  which  are  attached  the  distal 
ends  of  the  five  arms  referred  to.  Retraction  on  the  inner  rod  by  means  of 
screw  power  operates  each  of  the  arms  as  a  toggle  joint  forcing  it  outward, 
thus  increasing  the  circumference  of  the  instrument  at  this  point.  When 
in  use,  the  jointed  portion  of  the  shaft  should  be  covered  with  a  thin,  soft 
rubber  bag.  By  means  of  a  scale,  arranged  in  the  form  of  a  quadrant, 
and  a  suitable  arm  or  marker,  the  amount  of  dilatation  is  clearly  shown, 
and  may  at  all  times  be  noted.  A  ring  sliding  upon  the  shaft  may  be  used 
as  a  marker,  by  which  the  distance  that  the  instrument  is  inserted  into  the 
urethra  may  be  known. 


Figure  1347.    Weir's  Urethrometer. 


Weir's  Urethrometer,  as  shown  in  figure  1347,  consists  of  a  straight 
tubular  shaft,  its  outer  third  divided  into  longitudinal  halves.  By  means 
of  an  inner  rod,  attached  to  a  short  cross-bar,  similar  to  the  plan  employed 
in  the  construction  of  urethral  dilators,  the  split  blades  may  be  caused  to 
diverge  by  operating  the  thumb-screw  that  projects  from  the  proximal  end 
of  the  instrument.  The  tip  is  in  bulbous  form,  that  it  may  be  employed  in 
locating  strictural  bands.  A  dial  with  marker  indicates  the  amount  of 
divergence  of  the  blades. 

Treatment  of  Stricture. 

Strictures  of  the  urethra,  regardless  of  location,  may  be  treated  by  the 
following  methods:  Electrolysis;  gradual  dilatation;  rapid  dilatation,  or 


580 


GENITOURINARY    SURGERY. 


rupture ;  internal  urethrotomy ;  and  external  urethrotomy.     These,  with  the 
exception  of  external  urethrotomy,  may  necessitate  a  previous  meatotomy. 

Electrolysis. 

The  various  forms  of  batteries  and  electrical  currents  applicable  to  the 
treatment  of  urethral  stricture  will  be  found  described  in  the  chapter 
devoted  to  Electro-Therapeutics.  Such  currents  may  be  applied  by  elec- 
trodes of  various  forms,  a  limited  number  of  which  we  illustrate. 


Figure  1348.    Urethral  or  Intra-Uterine  Electrodes. 

Electrodes  for  use  in  the  urethra  or  uterus,  as  shown  by  figure  1348, 
may  be  rigid,  flexible  or  elastic,  and  may  have  any  size  or  shape  of  tip. 
For  uterine  use  the  flexible  electrodes  are  usually  preferred.  These  are 
also  generally  selected  for  use  in  the  urethra,  the  only  difference  being  that 
an  adjustable  set  of  tips  is  provided,  adapted  to  canals  of  varying  sizes, 
whether  normal  or  partially  closed  by  stricture.  Generally  the  French 
scale  is  employed  in  numbering  the  tips,  those  from  10  to  32  being  em- 
ployed as  a  rule. 


Figure  1349.    Newman's  Urethral  Electrode. 

Newman's  Urethral  Electrode,  as  illustrated  in  figure  1349,  consists  of 
a  straight  insulated  shaft,  terminating  in  a  curved  copper  tip.  They  may 
be  procured  of  various  sizes,  Nos."  12,  14,  16  and  18,  French  scale 
being  usually  preferred. 


Figure  1350.    Newman's  Olive-Tip  Urethral  Electrode. 


Newman's  Olive-Tip  Urethral  Electrode,  as  set  forth  in  figure  1351, 
consists  of  an  insulated  shaft  with  a  Van  Buren  curve,  and  provided  with  a 
metallic  olive-shaped  tip.  They  may  be  procured  of  any  size  from  Nos. 
10  to  30,  French  scale. 


Meatotomy. 

This  may  be  required  to  enlarge  the  external  opening, 
usually  required  are : 

Meatometers,  for  determining  the  size  of  the  meatus. 

Meatus  dilators. 

Meatotome,  or  other  knife,  for  incision. 

Sound,  for  maintaining  patency  of  opening. 


The  appliances 


MEATOTOMY. 


581 


Meatometers. 


These  consist  of  short,  straight,  conical,  graduated  sounds,  employed  for 
determining  the  size  of  the  meatus,  either  before  or  after  incision. 


Ffgure  1351.    Piffard's  Meatometer. 

Piffard's  Meatometer,  as  illustrated  by  figure  1351,  is  a  cone  about  3 
inches  in  length,  provided  with  a  flattened  handle  and  a  rounded  urethral 
end.  Well-marked  grooves,  about  ^  centimeter  apart,  encircle  the  instru- 
ment, each  stamped  with  a  number  representing  the  size  of  the  instrument 
at  that  point.  They  are  of  two  sizes,  the  small  ones  being  graduated  from 
15  to  26,  and  the  larger  from  26  to  38,  French  scale.  These  are  known  in 
the  market  as  small  and  large. 


Figure  1352.    Weir's  Meatus  Dilator. 


Figure  1353.     Kelly's  Meatus  Dilator. 


Weir's  Meatus  Dilator,  as  traced  in  figure  1352,  consists  of  two  wire 
blades,  caused  to  dilate  or  expand  by  a  coiled  spring  that  forms  part  of  the 
wire  from  which  the  blades  are  formed.  One  of  the  tips  presents  the  form 
of  a  bulb  split  longitudinally,  the  inner  surface  of  which  is  flat  with  a  serrated 
face.  The  opposite  blade  is  of  the  same  size,  but  fenestrated.  A  cross-bar 
with  set  screw  gives  the  operator  full  control  of  the  instrument.  It  is  suffi- 
ciently strong  to  obtain  any  amount  of  dilatation  that  may  be  required. 

Kelly's  Urethral  Dilator,  as  set  forth  in  figure  1353,  is  described  by 
•figure  1056,  as  a  calibrator  or  dilator  for  use  in  the  female  urethra. 

Meatotomes. 

Meatotomes  are  knives  with  probe  or  otherwise  guarded  points, 
employed  for  enlarging  the  meatus  by  direct  incision.  Generally  the 
operation  is  performed  with  a  short  probe-pointed  bistoury,  or  a  probe- 
pointed  tenotome.  Occasionally  a  surgeon  may  prefer  a  special  pattern, 
among  which  are  the  following: — 


Figure  1354.    Otis'  Meatotome. 

Otis'  Meatotome,  as  delineated  by  figure  1354,  is  a  small  center- point 
scalpel,  provided  with  a  spherical  tip,  located  directly  in  the  long  axis  of 
the  instrument. 

Lydston's  Meatotome,  as  traced  by  figure  1355,  *s  a  slender  scalpel,  the 
cutting  edge  of  which  presents  a  well-rounded  distal  extremity,  with  a 


582 


GENITOURINARY    SURGERY. 


slight  upward  curve  at  its  tip.  A  spherical  point  somewhat  larger  than 
that  of  Otis'  instrument,  projects  outward  and  upward  at  an  angle  of  about 
45°  with  the  line  of  the  handle. 


Figure  1355.    Lydston's  Meatotome. 

Civiale's  Meatotome,  as  shown  in  figure  1356,  is  in  the  form  of  a 
French  bistoury  cache,  or  one  in  which  the  knife  is  concealed  in  such  a 
manner  that  it  may  be  extended  from  its  guard  when  required  for  incision. 
It  consists  of  a  slender,  flattened,  slotted,  shaft,  containing  a  straight  bis- 


Figure  1356.    Civiale's  Meatotome. 

toury,  the  proximal  end  of  which  extends  in  the  form  of  a  lever  by  means 
of  which  the  knife  is  operated.  A  small  spring  keeps  the  knife  guarded 
until  pressure  is  made  upon  the  lever,  while  a  set  screw  regulates  the 
depth  of  the  incision.  This  should  be  set  at  the  required  point  before 
introduction.  This  instrument,  although  apparently  well  adapted  for  the 
purpose,  is  not  considered  an  improvement  on  the  patterns  previously 
referred  to. 

Meatus  Sounds. 

These  consist  of  short  conical  sounds  of  about  the  same  size  and  shape 
as  the  meatometers  previously  described.  They  are  employed  to  dilate 
strictures. 


Figure  1357.    Piffard's  Meatus  Sound. 


Piffard's  Meatus  Sound,  as  exhibited  in  figure  1357,  may  be  obtained 
in  two  sizes,  the  smaller  ranging  from  15  to  26,  and  the  larger  from  26  to 
38,  French  scale. 

Gradual  Dilatation. 

This  consists  in  the  introduction  at  intervals  of  a  series  of  graduated 
sounds  or  bougies,  the  former  being  generally  preferred.  Bougies 
•employed  for  the  purpose  of  dilatation  do  not  differ  from  those  used  for 
examinations,  a  full  description  of  which  will  be  found  on  page  570. 

TTrethral  Sounds. 

These  consist  of  metallic  rods,  employed  for  dilating  the  urethral  canal. 
They  may  be  either  straight  or  curved,  with  cylindrical,  conical,  bulbous  or 
tunneled  tips. 


GRADUAL    DILATATION    OF    THE    URETHRA. 


583 


The  regular  patterns  are  employed  to  dilate  strictures  in  the  bulbous 
portion  of  the  urethra,  or  to  produce  pressure  on  the  urethral  walls  for  the 
purpose  of  preventing  or  inhibiting  the  development  of  strictural  deposits. 

Ordinarily,  sounds  should  pass  through  the  urethra  by  their  own  weight. 
For  this  reason  no  effort  has  been  made  to  construct  them  of  light  material. 

Originally,  sounds  of  ordinary  patterns  were  forged  from  a  single  piece 
of  steel,  and  were  called  steel  sounds.  They  are  now  manufactured,  as  a 
rule,  from  charcoal  iron  rods  with  cast  steel,  iron  or  brass  handles,  the 
shaft  fitting  into  a  hole  bored  in  the  handle,  and  the  joint  soldered.  This 
cheaper  method  of  construction  has  resulted  in  a  greatly  reduced  price 
without  detracting  from  the  value  of  the  instrument. 

In  selecting  these  instruments,  the  surgeon  should  see  that  they  are  care- 
fully and  smoothly  finished,  regular  in  form  and  with  well-rounded  tips. 
Usually  they  are  numbered  with  the  various  scales  represented  by  each 
instrument.  For  instance,  one  5  millimeters  in  diameter  would  be  stamped 
with  three  numbers,  10  American,  15  French,  6  English,  while  one  5^ 
millimeters  in  diameter  would  be  stamped  with  but  one  number,  1 1  Amer- 


Figure  1338.    Standard  Curves  of  Unyielding  Urethral  Instruments. 

lean.  While  it  is  desirable  that  the  surgeon  should  supply  himself  with  a 
complete  series,  still,  alternate  sizes  in  the  American,  and  every  other  one 
or  every  third  size  in  the  French  series,  furnish  good  practical  sets,  partic- 
ularly for  surgeons  who  do  not  have  an  extensive  practice  in  this  class  of 
diseases. 

The  curved  varieties  vary  in  the  arc  of  the  circle  they  represent  and  in 
the  length  of  the  segment.  That  the  curves  recommended  by  various 
authorities  may  be  understood  and  compared,  we  here  insert  an  illustration 
in  detail  (figure  1358). 


584  GEN1TO-URINARY    SURGERY. 

Van  Buren's  Curved  Sound,  as  sketched  in  figure  1359,  represents  the 
most  common  form  of  sound  in  use;  in  fact,  it  is  so  generally  employed 
that  when  a  urethral  sound  is  mentioned  without  further  name  or  descrip- 


Figure  1359.    Van  Buren's  Curved  Sound. 

tion,  it  may  be  safely  assumed  that  this  pattern  is  the  one  desired.  They 
may  be  obtained  in  any  size,  varying  from  Nos.  2  to  24,  American  scale. 
The  two  smaller  sizes  are,  however,  seldom  employed,  as  they  are  so  small 
that  the  points  have  somewhat  sharp  terminations,  which  might  injure  the 
canal  on  introduction. 

Sets  of  Van  Buren's  Sounds,  with  or  without  cases,  may  be  obtained 
with  any  selection  of  numbers,  the  following  are  recommended: 

Set  of    8,  Nos.  4,  6,  8,  io,-i2,  14,  16,  18. 

'  12,  2,  4,  6,  8,  10,  n,  12,  13,  14,  15,  16,  18. 

'  16,  2,  4,  5,  6,  7,  8,  9,  10,  n,  12,  13,  14,  15,  16.  17,  18. 


TKUAX— GREENE-CH 

Figure  1360.    Lister's  Olive-Pointed  Sound. 


Lister's  Sounds  are  described  by  figure  1360.  As  designed  and  used  by 
Lister,  they  are  constructed  somewhat  after  the  pattern  of  an  olive-tip 
catheter,  curved  in  the  form  of  the  normal  urethra.  While  they  may  be 
procured  singly,  a  set  of  13  is  recommended  by  their  inventor,  embracing 
Nos.  i  to  13,  English  scale. 


X\*M   J 


Figure  1361.     Pratt's-Spooner's  Sound. 

Pratt' s-Spooner's  Sounds,  as  shown  by  figure  1361,  differ  from  the  pattern 
of  Van  Buren  in  having  a  lesser  curve.  The  sizes  recommended  by  Pratt 
are  every  third  number  from  5^  to  27,  French  scale. 


Figure  1362.    Weiss'  Sound. 

Weiss'  Sounds,  as  portrayed  by  figure  1362,  are  a  series  of  short  cylin- 
ders, about  2  inches  in  length,  one  of  which  is  attached  to  each  end  of  a 
rod-like  stem,  the  whole  forming  an  instrument  about  8  inches  in  length. 
The  tips  are  carefully  rounded,  the  whole  forming  an  instrument  compact 
and  easy  of  manipulation.  The  set  embraces  Nos.  9  to  20,  American  scale, 
two  sizes  being  on  each  stem. 


RAPID  DILATATION    OF    THE    URETHRA. 


585 


Fowler's  Curved  Sounds,  as  described  by  figure  1363,  are  practically 
duplicates  of  the  curved  portions  of  Van  Buren's  sounds.  The  two  sections 
representing  alternate  consecutive  numbers,  each  about  3^  inches  in 


Figure  1363.     Fowler's  Curved  Sounds. 


length,  are  attached  to  a  stiff  wire  rod,  the  whole  forming  an  instrument 
12  or  13  inches  in  length.     The  sizes  range  from  9  to  20,  French  scale. 

Goulay's  Tunneled  Sound,  as  shown  in  figure  1364,  is  similar  in  form 
to  the  pattern  of  Van  Buren.  It  differs  only  in  being  constructed  with  a 
groove,  that  commencing  near  the  middle  of  the  shaft  and  extending  for- 


Figure  1364.     Goulay's  Tunneled  Sound. 

ward  along  the  outer  border,  gradually  decreases  in  depth  until  a  short 
distance  from  the  point  where  it  terminates  in  a  tunnel  that  has  its  opening 
in  the  end  of  the  instrument.  As  a  filiform  bougie  may  be  passed  through 
the  tunnel  opening  and  its  body  allowed  to  rest  within  the  groove  of  the 
staff,  the  two  may  be  introduced  together  and  the  bougie  used  as  a  guide 
where  a  tortuous  canal  is  encountered.  The  sounds  may  be  obtained  in 
various  sizes. 


Figure  1365.    Goulay's  Tunneled  Catheter. 

Goulay's  Tunneled  Catheter,  as  traced  in  figure  1365,  comprises  a 
catheter  of  slender  construction,  the  posterior  or  outer  border  of  which 
contains  a  tunnel  similar  to  that  of  the  sound  just  described.  This  instru- 
ment is  intended  as  a  substitute  for  the  sound  in  cases  where  it  is  desirable 
to  draw  off  the  urine. 

Rapid  Dilatation  of  Rupture. 

Rapid  dilatation  or  rupture  consists  in  forcibly  stretching  or  tearing 
apart  the  fibrous  bands  forming  a  stricture,  completing  the  operation  at 
one  sitting.  The  instruments  designed  for  this  purpose  are  called  dilators. 
Dilators  for  distending  the  male  urethra  are  of  various  forms.  Usually 
they  consist  of  blades  provided  with  means  for  distending  or  spreading  them 
to  any  desired  extent.  The  cheaper  class  of  dilators,  as  a  rule,  expand 
nearly  if  not  entirely  throughout  their  length.  Others,  particularly  those  of 
modern  design,  are  constructed  so  as  to  suit  all  zones  of  the  urethra.  Suc- 
cess with  the  latter  instrument  requires  precision  in  treating  only  those  sec- 


586 


GENITOURINARY    SURGERY. 


tions  that  the  urethroscope  or  other  instruments  have  shown  to  be  diseased. 
With  the  exception  of  those  combined  for  dilatation  and  irrigation,  it  is  bet- 
ter that  all  be  covered  with  thin  rubber  tubes  that  they  may  not  be  brought 
into  immediate  contact  with  the  mucous  lining  of  the  urethra.  This  is  not 
only  advised  for  prophylaxis  against  infection,  either  of  the  patient  or  in- 
strument, but  it  guards  against  the  dangers  of  laceration  from  the  urethral 
lining  being  caught  between  the  blades  of  the  instrument,  a  not  uncommon 
occurrence.  Even  when  covered  with  rubber,  most  authors  advise  that 
after  dilatation,  when  the  instrument  has  been  reduced  to  its  normal  cali- 
ber, it  be  slightly  dilated  again  to  release  any  folds  that  may  have  been  in- 
cluded by  the  closing  of  the  blades. 

Rubber  covers  for  these  instruments  should  be  of  thin  material,  should 
fit  closely  and  should  be  tested  by  dilating  the  instrument  to  its  full  size 
after  the  cover  is  in  place  and  before  introduction.  As  folds  in  the  cover, 
either  in  introducing  or  removing  the  instrument  will  produce  more  or  less 
discomfort,  the  cover  should  be  sufficiently  tight  to  ensure  an  even  surface. 
When  in  place,  it  is  advisable  to  secure  the  proximal  end  with  a  thread, 
provided  it  encompasses  a  point  in  the  instrument  not  to  be  dilated.  Valen- 
tine advises  covering  the  dilating  portion  of  these  instruments  with  pow- 
dered talcum.  This  provides  lubrication  without  serious  danger  of  infection. 
A  slight  blow  on  the  instrument  after  use  will  remove  any  superfluous  pow- 
der. When  used  with  rubber  covers,  they  do  not  require  sterilization,  as  the 
latter,  unless  exercised  with  great  care,  might  tend  to  damage  the  delicate 
mechanism. 


Figure  1366.    Holt's  Dilator. 

Holt's  Dilator,  as  detailed  by  figure  1366,  consists  of  a  cylinder  divided 
into  halves  by  longitudinal  section,  thus  forming  two  concave  blades,  the 
two  united  at  their  vesical  ends  where  they  are  curved  like  an  ordinary  ure- 
thral sound.  A  slender  wire  rod  serving  as  a  guide  is  located  within  the 
divided  cylinder.  A  series  of  sounds  are  provided,  each  conical  at  the  tip 
and  constructed  with  an  opening  through  the  center,  large  enough  to  freely 
admit  the  central  rod  above  referred  to. 

Each  section  is  provided  with  a  handle,  the  two  connected  by  means  of 
a  clamp  and  set  screw,  in  such  a  manner  that  after  the  introduction  of 
the  dilating  shaft,  the  latter  may  be  held  firmly  in  place.  It  will  readily 
be  seen  from  the  above  illustration  and  description  that  successive  numbers 
of  the  dilators  may  be  passed  between  the  halves  of  the  blades  of  the 
instrument,  each  being  held  in  place  by  the  guide  or  central  rod  previously 
referred  to.  The  dilators  are  usually  six  in  number. 


RAPID    DILATION    OF    THE    URETHRA. 


587 


Thompson's  Dilator,  as  delineated  by  figure  1367,  has  a  cylindrical  body 
divided  by  longitudinal  sections  into  halves,  the  sections  united  at  the  dis- 
tal end  where  they  form  a  slightly  curved  probe-pointed  tip.  This  instru- 
ment is  dilated  antero-posteriorly  by  means  of  a  screw  controlled  by  a  handle. 
A  single  bar  provided  with  an  oblique  lever  forms  the  dilating  power.  The 


Figure  1367.    Thompson's  Dilator. 

degree  of  dilatation  is  shown  by  a  plain  scale.  As  instances  have  come  to 
our  notice  where  the  mucous  lining  has  been  caught  and  lacerated  in  an 
attempt  to  withdraw  instruments  of  this  class,  we  suggest  that,  during  the 
release  of  the  pressure,  the  instrument  be  slightly  rotated  from  right  to  left 
in  order  that  the  blade  openings  may  be  gradually  closed  and  the  tissues 
excluded  by  the  motion  referred  to. 


Figure  1368.    Goulay's  Dilator. 

Goulay's  Dilator,  as  exhibited  by  figure  1368,  differs  from  the  pattern  of 
Thompson,  in  dilating  laterally  and  in  being  constructed  with  a  more  sharply 
curved  beak  and  two  dilating  levers.  The  instrument  is  lighter  than  the 
pattern  of  Thompson. 


Figure  1369.    Lyon's  Urethral  Dilator. 

Lyon's  Urethral  Dilator,  as  explained  by  figure  1369,  is  applicable  in  the 
treatment  of  strictures  of  the  anterior  portion  of  the  urethra.     It  consists 


Figure  1370.    Nelaton's  Urethral  Dilator. 


of  two  lateral  shafts  united  at  their  point  in  an  olive-shaped  tip,  the  whole 
shaped  to  the  normal  urethral  curve.     By  means  of  a  screw  and"  nut  in  the 


GENITOURINARY    SURGERY. 


proximal  end  and  four  cross-bars  properly  attached,  the  instrument  may  be 
dilated.     Its  principal  advantage  is  the  low  price  at  which  it  is  sold. 

Nelaton's  Urethral  Dilator,  as  illustrated  in  figure  1370,  differs  from 
the  pattern  of  Lyon  last  described  in  being  intended  for  the  prostatic  por- 
tion of  the  urethra.  It  is  similar  to,  and  dilates  by  means  of  the  same 
mechanism  as  Lyon's  instrument. 


Figure  1371.    Oberlander's  Dilator  for  the  Anterior  Urethra. 


Figure  1372.    Oberlander's  Curved  Dilator  for  the  Bulbous  Portion  of  the  Urethra. 

Oberlander's  Dilators  for  the  anterior  and  bulbous  portions  of  the  urethra, 
as  shown  by  figures  1371  and  1372,  differ  only  in  that  the  shorter  one  con- 
fines the  dilatation  to  the  anterior  portion  of  the  urethra.  They  consist  of 
two  horizontal  shafts  that,  when  closed  and  resting  together,  present  a  smooth 
oval  form,  the  long  diameter  of  which  is  antero-posterior.  The  upper  shaft 
is  fixed,  and  to  it  is  attached  the  operating  mechanism.  The  lower  shaft  is  in 
three  parts,  all  hinged  together,  the  middle  section  of  which  is  slotted  and 
contains  two  or  more  oblique  bars,  the  ends  of  which  are  attached  to  each 
of  the  two  shafts.  A  nut  and  screw  advances  or  retracts  the  lower  blade, 
the  former  movement  securing  dilatation.  A  dial  and  marker  accurately 
measure  the  amount  of  expansion 


Figure  1373.    Oberlander's-Benique  Curved  Dilator. 

Oberlander's-Benique  Curved  Dilator,  as  traced  in  figure  1373,  differs 
from  the  patterns  previously  described,  in  the  extreme  prostatic  curve  de- 
scribed by  the  dilating  portion  of  the  instrument.  Instead  of  three,  six  or 
eight  hinged  pieces  are  necessary  in  the  construction  of  the  lower  blade,  in 
order  that  the  full  amount  of  dilatation  required  may  be  secured.  Usually, 
only  one  cross-bar  is  necessary.  This  instrument  is  used  when  exclusive 
dilatation  of  the  posterior  urethra  is  required. 


RAPID    DILATATION    OF    THE    URETHRA. 


589 


Ober lander's  Prostatic  Curved  Dilator,  as  represented  in  figure  1374, 
does  not  differ  from  the  patterns  previously  described,  excepting  in  the 
form  of  the  blades. 


Figure  1374.    Oberlander's  Prostatic  Curved  Dilator 

Kollman's  4-Bladed  Anterior  Dilator,  as  exhibited  in  figure  1375,  differ 
from  the  patterns  previously  described,  in  being  supplied  with  four  instead 
of  two  dilating  blades.  A  central  shaft  is  provided  to  which  the  expanding 


Figure  1375.    Kollman's  4-Bladed  Anterior  Dilator. 

bars  are  all  attached.  Four  blades,  one  anterior,  one  posterior  and  two  lateral 
are  attached  to  the  central  shaft  in  the  manner  previously  described.  By 
means  of  mechanism  similar  to  that  illustrated  in  the  pattern  of  Oberlander, 
any  amount  of  dilatation  may  be  secured. 


Figure  1376.    Kollman's  4-Bladed  Dilator  for  the  Posterior  and  Distal  Portions  of  the  Anterior 

Urethra. 


Figure  1377.     Kollman's  4-Bladed  Dilator  for  the  Posterior  Urethra. 

Kollman's  4-Bladed  Dilators,  as  shown  by  figures  1376  and  1377,  differ 
from  each  other  only  in  that  the  latter  is  constructed  for  the  exclusive  dila- 
tation of  the  posterior  urethra,  while  the  former  embraces,  as  well,  a  portion 


590 


GENITOURINARY    SURGERY. 


of  the  anterior  urethra.     In  other  respects  they  do  not  differ  from  the 
straight  pattern  previously  described. 


Figure  1378.    Kollman's  Posterior  Urethra  Irrigating  Dilator. 

Kollman's  Posterior  Urethra  Irrigating  Dilator,  as  exhibited  in  figure  1378, 
differs  from  the  patterns  previously  described  in  combining  means  for  irriga- 
tion with  mechanism  for  dilatation.  A  double -current  catheter  incorporated 
in  the  shaft  of  the  instrument  supplies  the  necessary  channel.  It  may  be 
attached  to  any  form  of  reservoir.  As  this  instrument  is  used  without  a 
rubber  cover,  great  care  must  be  taken  to  secure  surgical  sterilization.  Koll- 
man  advises  that  the  instrument  be  placed  for  an  hour  before  using  in  ab- 
solute alcohol,  the  latter  to  be  burned  off  the  instrument  on  its  removal. 
As  soon  as  cool,  the  dilator  should  be  held  in  a  vertical  position  in  a  bottle 
or  other  tall  vessel  and  boric  acid  solution  forced  through  both  of  the  cath- 
eter channels.  As  a  lubricant,  sterile  glycerine  or  a  similar  aseptic  prepa- 
ration may  be  employed.  After  use,  the  dilator  should  be  scrubbed  vigor- 
ously with  soap  and  water,  carefully  dried,  cleansed  with  benzine  applied 
with  a  tooth-brush  and  finally  with  absolute  alcohol. 

Internal  Urethrotomy. 

This  consists  in  severing  the  strictural  bands  with  some  form  of  knife. 
These  are  usually  called  urethrotomes. 

Urethrotomes . 

These  consist  of  small,  delicate  knives,  mounted  on  slender  shafts.  The 
blades  are  so  guarded  or  constructed  that  none  but  cicatricial  tissues  need 
be  severed.  Frequently  the  use  of  these  instruments  is  followed  by  the 
introduction  of  a  soft  rubber  catheter  of  proper  size,  the  latter  being  tied 
in  place  for  permanent  drainage  until  the  wound  heals. 

Usually  they  are  of  two  varieties,  those  cutting  from  front  to  back — 
direct,  and  from  back  to  front — retrograde.  A  few  patterns  of  these  instru- 
ments are  arranged  for  cutting  from  front  to  back,  after  which  the  blade 


Figure  1379.     Maisonneuve's  Urethrotome. 


may  be  withdrawn  through  the  same  incision  or  partially  turned  and  a  second 
opening  cut  from  back  to  front. 

Urethrotomes  cutting  from  front  to  back  are  most  commonly  in  use  and 
can  be  obtained  in  a  variety  of  patterns.  They  can  be  used  only  in  those 
cases  which  will  admit  the  passage  of  a  Xo.  6  sound  or  bougie.  American  scale. 


INTERNAL    URETHROTOMY  591 

Maisonneuve's  Urethrotome,  as  designated  by  figure  1379,  consists  of 
a  slender  grooved  shaft  of  small  caliber  curved  at  its  distal  end  like  an  ordi- 
nary sound,  but  with  a  longer  curve.  Two  knives  are  provided,  each 
mounted  upon  the  extremity  of  a  slender  elastic  steel  shaft  which  conforms 
to  the  curve  of  the  instrument. 

The  knives  represent  the  surface  of  two  inclined  planes  sloping  front 
and  back.  The  apex  of  the  knife  is  quite  blunt  and  presents  a  well-rounded 
margin.  The  larger  of  the  two  is  usually  about  30  millimeters  in  length 
by  8  in  breadth;  the  smaller,  25  in  length  by  6  in  breadth.  Small  handles 
are  provided  for  each,  by  which  they  may  be  manipulated. 

The  tip  of  the  urethrotome  is  somewhat  bulbous  in  form  and  removable, 
being  attached  with  thread  and  screw.  This  latter  feature  is  to  permit  the 
attachment  of  a  filiform  bougie,  two  of  which,  with  metal  connectors  that  fit 
the  tip  of  the  urethrotome,  are  provided  with  each  instrument.  These  bougies 
may  be  either  of  whalebone  or  elastic  web,  the  latter  being  usually  pre- 
ferred. A  straight  slender  rod  is  also  provided,  to  which  the  bougies  may  be 
attached.  This  is  for  exploratory  purposes  and  is  employed  in  passing  the 
bougie  through  the  stricture,  after  which  the  rod  is  detached,  the  urethrot- 
ome connected  and  introduced,  forcing  the  bougie  ahead  of  it  and  follow- 
ing it  along  the  urethral  canal.  This  instrument  enables  the  operator  to 
cut  from  front  to  back,  the  knife  being  withdrawn  through  the  same  incis- 
ion. The  instrument  is  of  delicate  construction  and  one  of  the  most  popular 
patterns  in  use. 


Figure  1380.    Tevan's  Modification  of  Maisonneuve's  Urethrotome. 


Tevan's-Maisonneuve's  Urethrotome,  an  illustration  of  which  is  shown  by 
figure  1380,  consists  of  a  central  tube  and  slotted  shaft,  the  blade  being  pro- 
tected by  a  sheath  extending  along  the  greater  portion  of  its  length.  It  is 
provided  with  a  stylet,  which  on  removal  shows  the  instrument  tip  to  be  in 
the  bladder,  as  is  evidenced  by  the  flow  of  urine  that  will  follow. 

It  is  intended  in  the  use  of  this  instrument  to  first  introduce  an  ordinary 
filiform  bougie,  followed  by  a  special  bougie  with  a  screw-end  attachment 
similar  to  those  used  in  the  pattern  last  above  described.  Instead  of  a  rod 
being  used  as  a  guide  for  the  bougie,  a  hollow  sound,  that  may  be  used  as  a 
catheter,  is  employed.  The  knife  is  attached  to  the  stylet  by  means  of  a 
screw,  thus  enabling  the  operator  to  remove  it  and  attach  it  to  the  bougie, 
by  which  it  may  be  guided  along  the  canal.  It  is  claimed  for  the  instru- 
ment that  it  possesses  advantages  not  found  in  the  original  pattern. 

Otis'  Straight  Urethrotome,  a  likeness  of  which  is  shown  in  figure  1381, 
is  one  of  the  most  popular  of  this  class  of  instruments.  It  consists  of  two 
parallel  shafts,  one  somewhat  heavy  and  rigid;  the  other  lighter,  jointed 
near  its  vesical  end  and  attached  to  the  heavier  one  by  means  of  a  hinge. 


592 


GENITOURINARY    SURGERY. 


Four  levers,  obliquely  placed  between  the  two  blades,  constitute  the  means 
by  which  distension  of  the  blades  is  secured.  The  lighter  blade  may  be 
forced  outward  by  a  fixed  screw,  thus  bringing  into  play  the  four  levers, 
whose  outer  ends,  moving  in  a  circle,  tend  to  produce  expansion  of  the  blades. 
The  amount  of  this  dilatation  is  accurately  measured  by  a  marker  and  scale. 
The  upper  portion  of  the  rigid  blade  is  slotted  or  curved,  admitting  the  intro- 
duction of  a  slender  stylet,  the  proximal  end  of  which  forms  a  small  and 


Figure  1381.    Otis'  Straight  Dilating  Urethrotome. 

exceedingly  thin  knife  blade.  The  slot  at  the  distal  end  of  the  instrument 
is  so  shaped  that  when  the  instrument  is  introduced,  the  blade  is  entirely 
concealed.  After  the  introduction  of  the  instrument,  by  slightly  withdraw- 
ing the  stylet,  the  blade  is  caused  to  protrude,  when,  by  withdrawing  the 
entire  instrument,  an  incision  may  be  made.  The  inventor  of  this  instru- 
ment formerly  employed  a  curved  pattern.  For  general  use  the  latter  has 
been  abandoned,  it  having  been  found  that  a  straight  instrument  answers 
«very  purpose.  A  duplicate  blade  accompanies  each  instrument. 


Figure  1382.    Gross1  Urethrotome. 

Gross'  Urethrotome,  as  outlined  by  figure  1382,  consists  of  a  grooved 
shaft  of  medium  size,  either  straight  or  shaped  to  about  the  normal  curve 
-of  the  urethra.  A  short  distance  from  the  distal  end  a  slight  bulb  is  formed 
in  the  instrument,  the  tip  of  the  latter  being  somewhat  smaller  than  the 
staff.  A  stylet  armed  with  a  small  knife  blade  upon  its  extremity  is 
passed  through  the  instrument,  the  blade  resting  within  the  small  bulb  pre- 
viously referred  to.  By  means  of  a  spring  and  mechanism  arranged  within 
the  handle,  the  blade  of  the  instrument  is  kept  within  the  bulb. 

By  pressure  upon  the  handle,  the  blade  may  be  protruded  toward  the 
point,  and  an  incision  made.  The  instrument  is  light  in  construction  and 
is  offered  for  sale  at  a  low  price. 

Gerster's  Urethrotome,  as  represented  in  figure  1383,  consists  of  a  shaft 
composed  of  three  parts,  one,  the  lower,  being  divided  into  two  dilating 
blades.  When  not  in  action,  these  blades,  oval  in  form,  rest  one  above  the 
other.  When  the  instrument  is  dilated,  they  are  caused  to  diverge,  thus 
placing  the  urethra  on  the  stretch,  the  better  to  prepare  it  for  incision.  To 
the  center  or  fixed  section  a  screw  mechanism  is  attached,  a  dial  being 
arranged  to  mark  the  amount  of  dilatation  secured.  The  outer  of  the  three 
main  sections  terminates  in  a  knife-like  blade,  which  is  concealed  within  the 
tip  when  the  instrument  is  introduced.  When  incision  is  desired,  the  blade 


INTERNAL    URETHROTOMY. 


593 


may  be  retracted  by  means  of  a  handle  projecting  upward  from  the  proxi- 
mal end  of  the  instrument. 


Figure  1383.    Gerster's  Urethrotome. 

Leinhardt's  Urethrotome,  as  illustrated  in  figure  1384,  consists  of  a  cylin- 
drical shaft  terminating  at  its  point  in  a  curved  beak  of  smaller  diameter 
than  the  body  of  the  instrument.  Within  the  latter  and  controlled  by  a  cen- 


Figure  1384.    Lienhardt's  Urethrotome. 

tral  rod,  a  double-edged  knife  with  lateral  cutting  edges  is  concealed. 
When  in  use  it  is  intended  to  penetrate  the  stricture  with  the  point  of  the 
instrument  until  the  shoulder  produced  by  the  change  to  the  larger  diameter 
rests  against  the  cicatricial  bands.  The  knife  is  controlled  by  a  spiral 
spring  and  thumb  ring,  so  that  when  desired  it  may  be  pushed  forward 
and  a  double  incision  made  from  front  to  back. 


Figure  1385.    Baxter's  Stricture  Cutter. 

Baxter's  Stricture  Cutter,  described  in  figure  1385,  the  simplest  of  all 
instruments  of  this  type  with  which  we  are  familiar,  is,  in  reality,  only  a 
blade  from  the  Maisonneuve  apparatus.  By  means  of  a  small  tunnel  in  the 
tip  of  the  instrument,  it  may  be  threaded  on  a  filiform  bougie.  The  knife 
is  not  brought  into  action  by  the  pressure  of  normal  urethral  walls.  When 
encroached  upon  by  strictural  bands,  it  is  at  once  brought  into  play,  the  lat- 
ter forcing  themselves  against  its  sharp  edges.  Its  inventor  claims  to  have 
used  the  instrument  with  great  success. 


Figure  1386.     Frudenberg's  Modification  of  Bottini's  Incisor. 

Freudenberg's  Modification  of  Bottini's  Incisor,  as  illustrated  by  figure 
1386,  is  shaped  like  a  lithotrite,  but  is  provided  with  a  thin  platino-iridium 
blade,  which,  when  the  instrument  is  closed,  is  concealed  within  the  beak. 

18 


594  GENITO-URINARY    SURGERY. 

This  blade  may  be  moved  backward  or  forward  by  means  of  a  thread  and 
screw,  a  slot  being  used  to  guide  the  instrument  in  the  same  maner  as  in 
the  lithotrite.  To  avoid  heating  a  double-curved  tube  is  provided,  by 
means  of  which  a  stream  of  cold  water  may  be  caused  to  circulate  through 
the  entire  length  of  the  instrument.  The  apparatus  is  used  not  only  for 
boring  a  new  urethra  through  an  enlarged  prostate,  but  for  cutting  through 
any  obstructing  bands  at  the  neck  of  the  bladder.  One  or  more  incisions 
may  be  made,  according  to  the  nature  of  the  case.  In  the  majority  of  cases 
it  is  claimed  that  no  general  anesthetic  is  required. 

External  Urethrotomy. 

This  may  be  necessitated  by  various  causes.  The  instruments  required 
comprise : 

Minor  operating  lists,  pages  270  to  275. 
External  urethrotomy  staff. 
Soft  rubber  catheter,  figure  1262. 

External  Urethrotomy  Staff. 

These  are  constructed  in  two  forms,  one  for  cases  where  such  an  instru- 
ment, if  of  small  caliber,  can  be  passed  through  the  stricture,  the  other  for 
those  in  which  an  entrance  can  not  be  so  secured. 


Figure  1387.    Symes'  External  Urethrotomy  Staff. 

Symes'  Staff,  for  external  urethrotomy,  consists  of  a  shaft  of  normal 
urethral  shape,  the  tip  or  curved  portion  being  of  much  smaller  diameter  than 
the  body  of  the  instrument.  As  is  made  clear  in  figure  1387,  the  change  in 
size  is  abrupt  and  forms  a  square  shoulder.  The  curved  portion  is  grooved 
along  its  outer  longitudinal  border  that  the  blade  of  the  incising  instrument 
may  be  guided  by  it  through  the  cicatricial  tissue.  The  shoulder  of  the  instru- 
ment is  intended  to  press  against  the  anterior  margin  of  the  strictural  band. 

Figure  1388.     Wheelhouse's  External  Urethrotomy  Staff. 

Wheelhouse's  Staff,  for  external  urethrotomy,  as  defined  in  figure  1388, 
is  applicable  in  cases  where  an  instrument  of  the  Symes'  pattern,  just 
described,  can  not  be  employed.  It  consists  of  a  straight  shaft  grooved 
throughout  its  length,  excepting  for  about  one-half  inch  at  its  distal  end. 
The  tip  turns  upward  with  a  slight  curve  and  terminates  in  a  button  form. 

Applications. 

Applications  are  usually  made  by  porte-caustiques,  applicators,  medicat- 
ing sounds,  syringes,  irrigators,  etc. 

Porte-Oaustiques. 

These,  when  constructed  for  use  in  the  urethra,  may  be  either  provided 
with  a  shield  for  use  without,  or  uncovered  when  used  with  a  speculum. 
They  are  now  little  employed. 


URETHRAL    APPLICATORS.  595 

Lallemand's  Porte-Caustique,  shown  by  figure  1389,  comprises  a  silver 
tube,  in  catheter  form,  with  a  sliding  revolving  cup  that  may  be  concealed 
within  the  instrument  tip  or  extended,  as  desired.  The  cup  is  cylindrical 
with  a  rounded  terminal  end,  and  is  provided  with  an  opening  in  one  side. 


Figure  1389.    Lallemand's  Porte-Caustique. 


The  chamber  thus  formed  may  be  used  to  contain  caustic  in  paste  form  and 
convey  it  to  the  diseased  surface.  The  stylet  is  spiral,  thus  permitting 
it  to  be  revolved,  so  that  the  open  side  of  the  instrument  may  be  turned 
in  any  direction.  A  set  screw  may  be  used  to  hold  the  stylet  in  any 
desired  position.  By  withdrawing  the  latter,  the  caustic  chamber  tele- 
scopes within  the  shaft. 


Figure  1390.    Grimfield's  Caustic  Holder. 


Grimfield's  Caustic  Holder,  as  set  forth  in  figure  1390,  resembles  Sims' 
sponge  holder,  differing  principally  in  the  form  of  the  teeth,  which  in  this 
instrument  are  shaped  to  grasp  a  caustic  stick.  A  sliding  ring  is  employed 
to  firmly  hold  the  cauterizing  agent.  The  handle  is  curved  downward. 
It  is  intended  for  use  through  a  urethroscope  or  speculum. 

Applicators. 

These  may  be  of  many  forms,  depending  largely  on  the  nature  of  the 
medicament  to  be  employed.  They  are  generally  used  through  some  form 
of  speculum. 


Figure  1391.    Plain  Urethra!  Applicator. 

The  Plain  Urethral  Applicator,  displayed  by  figure  1391,  is  intended  for 
use  with  a  speculum.     They  may  be  made  of  either  aluminum  or  copper. 


Figure  1392.    Grimfield's  Cotton  Holder. 


Grimfield's  Cotton  Holder,  as  illustrated  in  figure  1392,  differs  from  the 
caustic  holder  shown  in  figure  1390  only  in  the  shape  of  the  jaw  teeth. 
Small  balls  of  cotton  may  be  firmly  held  with  it. 


596 


GENITOURINARY    SURGERY. 


Grimfield's  Brush   Holder,  as  it    appears    in    figure   1393,  consists  of  a 
slender  shaft  to  which  a  small  brush  is  attached  by  a  screw  joint.     They 


TRUAX  GREENE-CO 


Figure  1393.    Grimfield's  Brush  Holder. 


are  employed  for  applying  medicaments  through  a  speculum, 
set  of  three  brushes  may  be  obtained  with  a  single  holder. 


Usually  a 


Figure  1394.    Lee's  Granule  and  Suppository  Applicator. 

Lee's  Applicator,  as  exhibited  in  figure  1394,  consists  of  a  tube  and 
obturator,  the  former  about  No.  12,  American  scale,  and  5  inches  in 
length.  The  obturator  has  a  bulbous  point,  and  when  retracted  is  held 
within  the  cylinder  by  a  screw  cap.  For  the  introduction  of  suppositories, 
it  is  necessary  to  remove  the  cap  and  place  the  former  within  the  cham- 
ber. Where  granules  are  employed,  they  may  be  dropped  into  the  cylinder 
through  the  side  opening  shown  in  the  illustration. 

Medicating  Sounds. 

These  consist  of  urethral  sounds,  provided  with  depressions  that  may 
be  filled  with  ointments  and  thus  conveyed  to  any  portion  of  the  urethra. 
The  sound  thus  charged  may  be  retained  until  the  ointment  has  been 
melted  by  body  heat  and  absorbed. 


Figure  1395.    Van  Buren's  Cup  Sound. 

Van  Buren's  Cup  Sound  is  certainly  the  best  known,  if  not  the  oldest 
pattern  among  this  class  of  instruments.  As  shown  by  figure  1395,  it 
differs  from  an  ordinary  sound  only  in  being  provided,  just  back  of  its 
curved  portion,  with  six  or  eight  oval  depressions. 


Figure  1396.    Rockey's  Cup  Sound. 

Rockey's  Cup  Sound,  as  portrayed  by  figure  1396,  consists  of  a  conical 
curved  sound  tip,  mounted  on  a  slender  shaft.  The  tip  is  pierced  with  a 
series  of  holes,  all  in  pairs,  and  directed  obliquely  toward  the  proximal 
end.  each  pair  so  adjusted  that  the  two  holes  are  united  into  one,  forming  a 
side-to-side  opening  as  shown  in  the  enlarged  figure. 


URETHRAL    SYRINGES. 


597 


Burt's  Medicating  Sound  differs  from  the  pattern  of  Van  Buren  in 
being  formed  with  a  series  of  circular  grooves  that  are  cut  in  the  circum- 
ference of  the  shaft.  These  grooves  are  about  half  an  inch  apart,  and,  as 
pictured  in  figure  1397,  extend  throughout  the  entire  shaft  of  the  instru- 


Figure  1397.     Burt's  Medicating  Sound. 

ment.     With  this  pattern,  applications  can  be  made  to  any  portion  of  the 
urethra. 

Syringes. 

Under  this  head  we  will  include  only  such  patterns  as  are  employed  for 
applications,  reserving  those  used  in  irrigation  for  a  special  section  to 
follow.  Generally  the  syringe  proper  is  less  important  than  the  tube  or 
pipe  through  which  injection  is  made.  These  are  in  great  variety,  vary- 
ing from  the  simple  forms  of  common  penis  tips,  used  in  the  treatment  of 
gonorrhea,  to  the  special  catheter  varieties,  employed  for  making  applica- 
tions to  the  prostate  or  neck  of  the  bladder. 


Figure  1398.    Plain  Hard  Rubber  Penis  Syringe 
with  Conical  Tip. 


Figure  1399.    Davidson's  Soft  Rubber  Penis 
Syringe. 


The  Conical-Tip  Hard  Rubber  Syringe,  indicated  by  figure  1398,  of 
either  ^  or  ^  ounce  capacity,  is  probably  the  most  popular  pattern  in  use. 
The  tip  when  firmly  pressed  into  the  meatus  forms  a  water-tight  connec- 
tion. When  made  with  a  ring  handle,  the  instrument  is  easily  manipulated 
with  one  hand  by  either  physician  or  patient. 


Figure  1400.    Ware's  Penis  Syringe  for  Patients. 


Figure  1401.  Davol's  Soft  Rubber  Penis 
Syringe. 


Ware's  Penis  Syringe,  as  shown  by  figure  1400,  is  made  of  glass  with  a 
conical  tip  and  removable  plunger.  The  packing  is  of  soft  rubber,  and 
can  be  easily  cleansed.  Its  principal  feature  is  a  sliding  bottle  stopper 
surrounding  the  glass  barrel.  This  may  be  used  as  the  permanent  stopper 
of  the  bottle  containing  the  injection,  or  employed  as  a  means  for  filling 
the  syringe.  By  pushing  the  stopper  along  the  barrel  until  flush  with  the 
syringe  tip,  and  crowding  it  into  the  bottle  neck  by  inverting  the  bottle, 
the  syringe  may  be  filled. 

Davidson's  Penis  Syringe,  as  exhibited  in  figure  1399,  is  of  rubber,  soft 
and  elastic.  Its  capacity  is  about  ^  ounce. 


598 


GENITO-URTNARY    SURGERY. 


They  are  advised  for  patients'  use  because  there  is  little  liability  to 
auto-injury. 

Davol's  Penis  Syringe,  as  represented  in  figure  1461,  is  also  made  from  soft 
rubber.  As  it  is  moulded  with  a  conical  tip,  it  possesses  all  the  advantages 
of  the  syringe  shown  in  figure  1398,  and  may  be  filled  as  easily  as  the  pattern 
of  Ware  previously  described.  By  holding  the  conical  tip  against  the  inverted 
open  mouth  of  the  bottle  containing  the  fluid  to  be  injected,  the  air  in  the 
syringe  may  be  forced  into  the  bottle  by  a  series  of  partial  compressions, 
and  replaced  with  fluid.  This  can  be  done  without  spilling  a  drop,  thus 
furnishing  one  of  the  best  of  the  portable  syringes  for  patients'  use. 


Figure  1402.    Bumstead's  Urethral  Syringe. 

Bumstead's  Urethral  Syringe,  as  depicted  in  figure  1402,  consists  of  a 
small  syringe  with  a  glass  barrel  and  ring  handle.  Usually  it  is  of  2 
drachms'  capacity.  The  syringe  pipe  is  about  6  inches  in  length,  is 
slightly  curved  and  of  brass  or  silver,  the  latter  being  preferred. 


Figure  1403.    Ultzmann's  Urethral  Syringe. 


Ultzmann's  Urethral  Syringe,  as  delineated  in  figure  1403,  differs  from 
the  pattern  of  Bumstead  in  its  syringe  pipe,  which  in  this  pattern  is  more 
sharply  curved. 


Figure  1404.    Guyon's  Deep  Urethral  Syringe. 

Guyon's  Deep  Urethral  Syringe,  as  imaged  in  figure  1404,  differs  from 
the  pattern  before  described  principally  in  its  discharge  pipe.  This  is 
about  12  inches  in  length,  of  elastic  web  and  has  an  olive- tip.  The  latter 
serves  to  mark  a  point  of  stricture,  so  that  when  desired,  injections  may 
be  directed  upon  the  involved  tissues. 


Figure  1405.    Janet's  Syringe. 


Janet's  Syringe,  as  pictured  in  figure  1405,  is  of  metal, of  about  4  ounce 
capacity,  and  so  constructed  that  it  is  separable  for  cleansing.  It  consists 
of  a  barrel  and  tip  in  a  single  piece  with  a  removable  cap  and  piston.  The 
former  is  supplied  with  finger  rings  that  assist  in  expelling  the  syringe 


URETHRAL    IRRIGATION. 


599 


contents,  while  the  cap  is  held  in  place  by  suitable  flanges.     It  is  employed 
principally  in  washing  out  the  urethra  preliminary  to  operation. 

Irrigation. 

Irrigation  may  be  secured  with  a  bulb  or  fountain  syringe  or  special 
irrigating  apparatus.  Like  the  tips  or  pipes  used  in  making  urethral 
applications,  there  is  a  great  variety  of  forms,  for  each  of  which  special 
merits  are  claimed  by  its  inventor. 


TRIMS,  GREENE  &  Co. 
Figure  1406.    Otis'  Syringe  Nozzle. 


*-GREENE-CO. 


TRUflX-GREENE-CO. 


Figure  1407.    Valentine's  Glass  Syringe  Nozzles. 


Figure  1408.     Lydston's  Syringe  Nozzle 
with  Shield. 


Otis'  Syringe  Nozzle,  as  disclosed  by  figure  1406,  consists  of  a  metallic 
tube  closed  and  rounded  at  its  distal  end;  its  sides  for  about  one-half  its 
length  being  perforated  with  multiple  minute  openings.  A  collar  near  the 
proximal  end  prevents  the  pipe  from  being  introduced  to  too  great  a  depth. 
Its  length  is  about  4  inches. 

Valentine's  Injection  Nozzles,  as  drawn  in  figure  1407,  are  tubular, 
with  large  tips.  This  pattern  of  nozzle  acts  as  a  reservoir  in  securing  a 
uniform  flow.  A  second  pattern  recommended  by  the  same  author  is  con- 
structed with  a  rounded  end  as  shown  in  the  same  illustration. 

Lydston's  Syringe  Nozzle  and  Shield,  as  illustrated  in  figure  1408, 
combines  with  a  bulbous  discharge  tip  a  shield  of  sufficient  size  to  act  as 
a  guard,  preventing  the  outward  spurting  fluid  from  coming  in  contact 
with  the  fingers  or  splashing  on  the  clothing  of  the  attending  surgeon.  It 
is  of  hard  rubber  and  is  separable  for  cleansing. 


Figure  1410.     Reefer's  Nozzle. 


Figure  1411.    Valentine's  Cut-off. 


Keefer's  Nozzle,  as  it  appears  in  figure  1410,  is  a  forked  tube,  arranged 
to  admit  a  flow  of  water  into  the  urethra,  and  permitting  the  same  to  pass 
out  by  the  natural  process  of  contraction.  One  fork  of  the  tube  may  be 
connected  with  a  fountain  syringe,  the  other  with  an  escape  pipe.  The 
double  portion  of  the  tube  is  somewhat  bulbous  in  form  and  when  in  oper- 
ation is  introduced  into  the  external  meatus,  securing  a  contact  firm 
enough  to  prevent  a  flow  of  fluid  from  passing  between  the  nozzle  and  the 


600 


GENITOURINARY    SURGERY. 


mucous  lining.  While  the  urethra  is  being  filled,  the  exit  pipe  should  be 
closed  by  compression  with  the  thumb,  finger,  or  a  suitable  cut-off.  While 
the  urethra  is  being  emptied,  the  pipe  leading  to  the  fountain  syringe 
should  be  similarly  closed. 


Figure  1409.     Urethral  Retrojector. 

The  Urethral  Retrojector,  defined  by  figure  1409,  is  a  slender  tube  of 
catheter  form,  provided  with  an  acorn-shaped  bulb.  The  latter  is  per- 
forated in  its  base  with  several  minute  openings,  all  in  the  direction  of  the 
meatus.  By  means  of  this,  the  current  after  reaching  the  tip,  is  reversed, 
and  issuing  in  small  jets,  flushes  or  washes  out  the  urethra. 


Figure  1412.    Valentine's  Irrigat- 

ing  Apparatus  with  Sliding 

Bracket. 


Figure  1413.    Valentine's  Irrigat- 

ing  Apparatus  with  Stationary 

Bracket. 


Figure  1414.    Burr's  Irrigat- 
ing Apparatus  with  Stop- 
Pulley. 


Valentine's  Irrigating  Apparatus,  as  outlined  in  figures  1412  and  1413, 
differ  only  in  that  one  has  a  stationary  and  the  other  a  sliding  reservoir 
holder  or  bracket.  The  apparatus  comprises  a  tank  of  4o-ounce  capacity, 
connected  by  rubber  tubing  with  a  cut-off  and  shield  of  special  design.  The 
reservoir  is  of  glass,  conical,  in  percolator  form.  A  nipple  at  the  bottom 


REMOVAL    OF    FOREIGN    BODIES. 


601 


and  a  flaring  tip  on  the  end  of  the  rubber  tubing  form  a  safe  union.  The 
reservoir  may  be  attached  to  a  fixed  bracket,  as  shown  in  the  second  illus- 
tration, or  to  one  that  may  be  caused  to  slide  up  or  down  along  a  fixed 
track.  By  means  of  stops,  the  bracket  and  tank  may  be  held  at  any  desired 
height,  thus  securing  a  variable  hydrostatic  force.  The  track  will  be 
found  a  convenience  in  filling  the  reservoir,  as  the  latter  can  be  let  down 
to  a  height  within  easy  reach.  A  sliding  cut-off  is  employed,  so  adjusted 
that  by  moving  a  ring  along  a  tube  or  handle,  two  lateral  jaws  are  caused 
to  clamp  and  close  the  tube.  The  tips,  although  usually  conical,  may  be 
of  any  form,  from  round  ends  to  the  old  style  syringe  pattern.  For  use 
with  permanganate  of  potassium  and  other  fluids  objectionable  to  the  sur- 
geon, a  shield  is  provided,  by  means  of  which  the  return  flow  from  the 
meatus  is  prevented  from  striking  the  hand  of  the  operator,  and  is  safely 
conducted  to  a  receptacle  below.  These  shields  may  be  of  metal  or  glass; 
the  former  is  preferred  because  it  is  light  and  unbreakable,  the  latter 
because  it  can  be  more  easily  cleaned. 

Burr's  Irrigating  Apparatus,  as  detailed  in  figure  1414,  differs  from  the 
pattern  of  Valentine  in  being  of  more  simple  construction  and  conse- 
quently less  expensive.  The  reservoir,  which  is  of  practically  the  same 
pattern,  is  suspended  by  a  flat  link  chain  and  cord,  by  means  of  a  stop- 
pulley  attached  to  the  ceiling.  The  rubber  connecting  tube  is  the  same  as 
in  the  pattern  of  Valentine.  The  stop-cock  is  of  a  new  pattern,  and  is 
controlled  by  a  spring  push  button  or  check  valve,  while  the  shield  and 
urethral  tips  are  of  plain,  light,  though  efficient  construction. 

Removal  of  Foreign  Bodies. 

Foreign  bodies  may  be  removed  by  mechanical  devices,  the  nature  of 
which  must  depend  on  the  character  and  location  of  the  foreign  substance. 
Generally,  such  appliances  consist  of  forceps,  sounds,  etc. 

Foreign  Body  Forceps. 
Forceps  for  Removing  Foreign  Bodies  from  the  urethra  are  necessarily 


TRUAX&C2 

Figure  1415.    Thompson's  Urethral  Forceps. 


of  slender  construction,  well  rounded  and  free  from  angular  or  uneven 
surfaces.      The  jaws   at   their  lateral   margins   should   fit   accurately  and 


Figure  1416.    Pitha's  Urethral  Forceps. 

smoothly,  that  their  use  may  not  lacerate  the  mucous  surfaces  with  which 
they  may  be  brought  in  contact. 


I II:  cMr  n  MS 


602 


GENITOURINARY    SURGERY. 


Thompson's  Urethral  Forceps,  as  sketched  in  figure  1415,  are  straight, 
of  slender  construction,  about  8  inches  in  length  and  hinged  near  the 
handles.  When  closed,  they  are  slender  in  form,  and  for  this  reason  can  be 
easily  passed  along  the  urethra. 

Pitha's  Urethral  Forceps,  as  delineated  in  figure  1416,  differ  from  the 
pattern  of  Thompson  only  in  being  somewhat  heavier  and  curved  on  the 
flat. 


Figure  1417.    Collins'  Urethral  Forceps. 

Collins'  Urethral  Forceps,  as  shown  in  figure  1417,  consist  of  a  tube  and 
inner  shaft,  the  distal  ends  of  which  are  formed  into  jaws  that  are 
actuated  by  a  thumb-piece  attached  to  the  handle.  This  instrument  is  of 
delicate  construction,  and  although  not  larger  than  No.  7,  American 
scale,  the  jaws  work  perfectly  with  good  grasping  power.  The  mechanism 
is  well  explained  in  the  illustration. 


Figure  1418.  Matthieu's  Alligator  Urethral  Forceps. 

Matthieu's  Alligator  Urethral  Forceps,  as  explained  in  figure  1418,  do 
not  differ  from  the  pattern  described  by  figure  1218  excepting  that  they  are 
straight. 


Figure  1419.    Collins'  Urethral  Scoop. 

Collins'  Urethral  Scoop,  as  detailed  in  figure  1419,  consists  of  a  tube 
and  shaft,  the  latter  terminating  in  a  small  hinged  scoop  that,  by  means  of 
a  handle,  may  be  turned  at  right  angles  with  the  shaft  of  the  instrument. 
It  is  well  adapted  for  use  in  dragging  out  any  urethral  foreign  body.  When 
in  a  normal  position,  the  scoop  portion  is  only  an  extension  of  the  instru- 
ment. If  the  point  be  once  passed  beyond  the  foreign  substance  its 
removal  is  easy. 

SURGERY  OF  THE  PROSTATE. 

In  the  light  of  modern  surgery,  it  does  not  seem  advisable  to  include  any 
of  the  long  lists  of  instruments  that  have  been  invented  and  used  in  opera- 
tions upon  the  prostate  gland  in  the  past.  All  of  the  instruments  now 
necessary  for  operations  on  this  organ  may  with  propriety  be  included 
with  those  pertaining  to  urethral  surgery.  The  instruments  necessary  for 
perineal  operations  do  not  differ  from  those  formulated  for  perineal  lithot- 
omy or  external  urethrotomy,  and  to  these  lists  the  reader  is  referred.  The 
only  exception  to  the  above  might  be  the  operation  of  Bottini,  and  this,  as 
now  modified  and  generally  adopted,  has  been  referred  to  in  the  section  de- 
voted to  surgery  of  the  urethra. 

'f-r<^ 


SURGERY    OF    THE    PENIS. 


603 


SURGERY  OF  THE  PENIS. 

The  appliances  required  in  the  various  operations  on  this  organ  may  be 
classified  as  instruments  for  amputation  and  phimosis. 

Amputation. 

This  procedure  may  be  conducted  by  the  use  of  the  minor  operating  in- 
struments described  on  pages  270  to  275.  A  catheter  is  usually  passed  into 
the  bladder  before  excision,  permanent  drainage  and  the  patency  of  the 
canal  being  thus  secured  during  and  following  the  operation. 

Phimosis. 

This  may  be  relieved  by  circumcision,  dilatation  or  incision,  the  latter 
requiring  no  special  instruments. 

Circumcision. 

This  procedure  will  require  the  following  list  of  instruments: 

Tissue  or  other  forceps,  for  drawing  prepuce  forward,  figure  604. 

Phimosis  forceps  or  clamp,  for  holding  prepuce. 

Scalpel  for  excision,  figures  550  to  565. 

Needles,  figures  739  to  749. 

Sutures,  figures  708  to  728. 

Dressings,  figures  791  to  794. 

Phimosis  Forceps. 

These  consist  of  long  or  broad-bladed  forceps  used  to  hold  the  prepuce 
during  excision  and  suturing.  The  blades  vary  in  form,  from  a  straight 
slender  pattern  to  one  of  T-shape.  Some  are  fenestrated,  that  the  incision 
may  be  made  through  the  blade  openings,  others  are  perforated  with  needle 
holes,  that  the  sutures  may  be  accurately  adjusted,  while  a  late  pattern  is 
slotted  along  the  blade  margins,  that  the  sutures  may  be  quickly  and  regu- 
larly inserted. 


Figure  1421.    Ricord's  Phimosis  Forceps. 


Figure  1422.    Fisher's  Phimosis  Forceps 


Figure  1420.    Plain  Phimosis  Clamp. 


Figure  1423.     Skillern's  Phimosis  Forceps. 


The  Plain  Phimosis  Clamp,  as  shown  by  figure  1420,  consists  of  a  thin 
strip  of  metal  containing  a  slender  V-shaped  opening.  This  opening  is 
usually  about  2  inches  in  length  by  ^  of  an  inch  in  breadth,  at  its  mouth  or 
largest  part.  If  the  prepuce  be  drawn  closely  within  the  narrow  portion  of 


G04 


GENITOURINARY    SURGERY. 


the  slot,  the  instrument  will  act  as  a  clamp,  not  only  for  the  purpose  of  fur- 
nishing a  firm  hold  upon  the  tissues,  but  as  a  hemostatic  agent. 

Ricord's  Phimosis  Forceps,  as  depicted  in  figure  1421,  have  scissors 
handles  and  long  fenestrated  jaws.  The  latter  at  their  extreme  tips  are 
provided  with  transverse  serrations,  while  each  of  the  jaw  margins  contains 
longitudinal  grooves.  The  slot  may  be  utilized  for  the  passing  of  sutures, 
either  before  or  after  incision. 

Fisher's  Phimosis  Forceps,  as  sketched  in  figure  1422,  have  spring  blades 
slightly  curved  on  the  edge.  The  jaws  throughout  their  entire  length  are 
provided  with  oblique  serrations.  A  number  of  small  openings  through 
both  blades  permit  the  passage  of  the  needle  in  suturing.  A  cross-bar  and 
nut  maintain  the  desired  amount  of  compression.  The  tips  of  the  blades 
have  mouse  teeth  to  insure  perfect  approximation. 

Skillern's  Phimosis  Forceps,  as  defined  by  figure  1423,  are  of  the  cross- 
action  type  with  jaws  fenestrated  similarly  to  the  pattern  of  Ricord. 


Hall's  Phimosis  Forceps,  as  illustrated  in  figure  1424,  are  longer  than 
the  pattern  of  Skillern,  are  not  perforated  and  are  bent  on  the  edge  at  an 
angle  of  135°. 

Dilatation. 
This  may  be  secured  by  the  use  of  appliances  known  as  dilators. 

Preputial  Dilators. 

These  usually  consist  of  two  or  more  blades  caused  to  diverge  or  spread 
apart  by  leverage  or  screw  power. 


Figure  1425.    Bennet  s  Preputial  Dilator. 


Bennet's  Preputial  Dilator,  as  detailed  in  figure  1425,  consists  of  three 
blades,  all  of  which  are  caused  to  dilate  by  handle  compression.  The  third 
or  lower  blade,  as  shown  in  the  illustration,  is  attached  to  a  toggle  joint  that 
is  actuated  by  the  movement  of  the  handle.  A  steel  spring  tends  to  close 
the  blades,  while  a  set  screw  enables  the  operator  to  fix  them  when  the 
desired  amount  of  dilatation  has  been  secured. 


SURGERY    OF    THE    SCROTUM    AND    ITS    CONTENTS. 


605 


SURGERY  OF  THE  SCROTUM  AND  ITS  CONTENTS. 

The  appliances  that  are  required  in  operations  on  or  within  the  scrotum 
may  be  classified  as  those  for  scrotal  suspension ;  compression  apparatus  for 
swelling;  amputation ;  castration ;  varicocele  and  hydrocele. 

Scrotal  Suspension. 

This  may  be  necessitated  by  various  causes,  for  which  many  forms  of  ap- 
pliances are  in  use.  Usually  they  are  in  sack  form,  supported  by  a  hip  belt. 
Some  patterns  are  manufactured  with  perineal  straps  which  fasten  posteri- 
orly to  the  waist  band.  They  are  made  from  silk,  linen  and  cotton.  What- 
ever be  the  material  chosen,  it  should  be  fine  and  soft.  Many  makes  are 
offered  that  are  of  such  coarse  weave  that  linear  constriction  results. 


Figure  1426.     Plain  Suspensory  Bandage. 


Figure  1427.    Suspensory  Bandage  with  Perineal 
Bands. 


The  Plain  Suspensory  Bandage,  indicated  in  figure  1426,  consists  of  a  scro- 
tal bag  attached  to  a  plain  hip  band.  The  sizes  are  usually  known  as  small, 
medium,  large  and  extra  large. 

The  Suspensory  Bandage,  with  Perineal  Straps,  as  set  forth  in  figure 
142  7,  differs  from  the  plain  pattern  previously  described,  in  that  the  posterior 
portion  of  the  sack  is  supported  and  held  in  place  by  two  straps  that  pass 
under  the  perineum  and  are  attached  to  the  hip  belt.  The  sizes  are  the 
same  as  those  last  mentioned.  Both  of  the  foregoing  can  be  procured  in 
cotton,  linen  and  silk. 

Scrotal  Compressing  Apparatus. 


Figure  1428.     Hawes'  Compressor. 


Figure  1429.    Carroll's       Figure  1430.    Miliano's  Compressor. 
•Compressor. 


These  appliances,   without   regard  to  the  nature  of   the  swelling,  are 
usually  some  form  of  lacing  or  elastic  device. 


606  GENITOURINARY    SURGERY. 

Hawes'  Orchitis  Compressor,  as  shown  in  figure  1428,  is  a  soft  rubber 
bag  with  double  wall  so  arranged  that  the  enclosed  wall  space  may  be  en- 
larged by  injecting  into  it  air  or  water.  The  latter  may  be  hot,  thus  secur- 
ing the  benefits  of  both  heat  and  compression.  They  are  manufactured  to 
order,  to  suit  the  requirements  of  special  cases. 

Carroll's  Orchitis  Compressor,  as  it  appears  in  figure  1429,  is  a  bag  of 
firm  material,  usually  webbing.  One  side  is  provided  with  an  opening, 
which  may  be  increased  or  diminished  at  will,  by  means  of  a  cord  and  lacing 
hooks.  A  metal  band  of  flexible  material  properly  applied,  exerts  an  elas- 
tic tension  on  the  swollen  testicle,  thus  tending  to  reduce  its  size.  It  pos- 
sesses an  advantage  over  many  other  varieties,  in  that  the  patient  may  ap- 
ply or  remove  it  as  desired. 

Miliano's  Varicocele  Compressor,  as  traced  in  figure  430,  consists  of  a 
bag  of  netting  arranged  with  three  or  more  sets  of  lacing  bands  or  cords. 
The  instrument  is  applied  by  enclosing  the  entire  scrotum.  The  upper 
band  is  first  tightly  drawn  and  secured  to  prevent  the  escape  of  the  testes. 
The  bandage  is  next  drawn  down  tightly  and  tied  close  under  the  scrotum. 
After  these  are  secured,  any  intermediate  cords  may  be  tightened  as  the 
case  may  require, 

Scrotal  Amputation. 

Excision  of  any  portion  of  the  scrotum  requires  the  following  list  of  in- 
struments : 

Scrotal  clamp. 

Tissue  forceps,  for  grasping  parts  of  excision,  figure  604. 

Knife  for  incision,  figures  550  to  565.  ,, 

Small  artery  forceps  or  serresfins,  figures  647  to  672. 

Needles,  figures  739  to  749. 

Sutures,  figures  708  to  728. 

Dressings,  figures  791  to  794. 

Scrotal  Clamps. 

These  are  employed  to  grasp  and  hold  the  scrotum  along  the  line  of  ex- 
cision. They  may  be  in  the  form  of  plates  or  forceps  blades  and  controlled 
by  spring  or  screw  power. 


igure  1431.     Henry's  Scrotal  Clamp. 

Henry's  Scrotal  Clamp,  as  pictured  in  figure  1431,  has  two  double-curved 
blades  of  the  self-closing  spring  pattern.  The  contact  portions  or  jaws  are 
about  6  inches  in  length,  the  coapting  surfaces  being  evenly  notched  with 
transverse  serrations  that  serve  to  prevent  slipping  of  the  tissues.  A  set 
screw  in  the  handle  prevents  the  instrument  from  becoming  too  widely 
separated  at  the  proximal  end  of  the  jaw.  A  fly  nut  at  the  distal  ends  serves 
to  maintain  a  uniform  approximation  throughout  the  entire  length  of  the 
blades. 

The  outer  surface  of  the  curve  is  supplied  with  a  separable  spring  guard 
that  when  in  use  forms  a  fenestra  about  ^  of  an  inch  wide.  When  applied 


CASTRATION    AND    VARICOCELE.  607 

in  front  of  the  scrotum,  it  should  include  outside  of  tne  curve,  the  portion 
of  the  sac  to  be  removed.  It  is  intended  to  employ  the  fenestra  as  an 
aid  in  placing  the  necessary  sutures.  It  may  also  be  used  as  a  guide  for 
the  knife  blade  during  excision. 


Figure  1435.     King's  Scrotal  Clamp.  Figure  1433.    Artificial 

Testis. 

King's  Scrotal  Clamp,  as  depicted  in  figure  1432,  consists  of  two  blades 
curved  on  the  edge  and  forged  from  a  single  piece  of  steel,  the  loop  necessa- 
rily formed  constituting  the  handle.  The  inner  face  of  the  coapting  surfaces 
are  provided  with  longitudinal  grooves,  that  the  margins  may  form  a  better 
contact  with  the  tissues.  Winged  nuts  turning  on  cross-bolts  at  each  end  fur- 
nish means  for  securing  the  desired  amount  of  pressure.  A  series  of  holes 
bored  through  both  blades,  each  connected  with  the  outer  border  by  means  of 
slots,  furnish  the  means  for  the  accurate  application  of  all  necessary  sutures. 
The  instrument  is  of  light  construction,  its  entire  length  not  exceeding  7 
inches. 

Castration. 

This  operation  requires  nearly  all  of  the  minor  operating  instruments 
described  on  pages  270  to  275.  No  special  instrument  is  required  unless 
the  surgeon  desires  to  replace  the  removed  member  or  members  with  arti- 
ficial substitutes. 

Artificial  Testes. 

These  are  employed  in  special  cases  where  the  patient  is  not  advised  that 
castration  has  been  performed,  substitution  being  made  with  an  artificial 
organ  of  the  proper  size  and  form. 

Artificial  Testes,  as  represented  in  figure  1433.  may  be  of  solid  ivory, 
aluminum  or  celluloid  and  of  hollow  silver.  The  latter,  although  the  most 
expensive,  is  to  be  preferred. 

Treatment  of  Varicocele. 

This  affection  may  be  treated  by  either  palliative  or  operative  measures. 
The  former  include  the  use  of  suspensory  bandages,  compressors,  etc. ,  fully 
described  by  figures  1426  to  1430.  Operative  procedures  may  be  by  acupress- 
ure to  obstruct  the  venous  circulation,  by  ligation  or  by  incision. 

Acupressure. 

This  may  be  secured  by  the  use  of  needles  or  pins  of  the  regular  form, 
such  as  are  described  by  figures  680  to  684. 

Ligation. 

This  is  applicable  in  a  large  percentage  of  cases.  As  generally  under- 
stood, it  implies  a  subcutaneous  method  by  means  of  which  the  enlarged 
veins  may  be  ligated.  The  appliances  necessary  are  needles  and  ligatures. 


608 


GENITOURINARY    SURGERY. 


Varicocele  Needles. 


These  consist  of  needles  with  fixed  handles  by  means  of  which  they  may 
be  accurately  manipulated. 


Figure  1434.    Whitfield's  Varicocele  Needle. 

Whitfield's  Varicocele  Needle,  as  shown  in  figure  1434,  has  a  strong  shaft 
with  a  sharp  point,  a  closed  eye  and  a  suitable  handle.  It  is  employed  to 
carry  a  threaded  ligature  through  the  scrotum  upon  one  side  of  the  vessel 
to  be  ligated.  It  is  intended  to  be  unthreaded  upon  the  opposite  side,  after 
which  the  needle  is  withdrawn  and  passed  through  the  same  external 
opening,  but  upon  the  opposite  side  of  the  vein  where  it  is  re-threaded  and 
the  suture  withdrawn,  thus  encircling  the  vessel  to  be  ligated. 


TRUAX   &  CO. 

Figure  1435.    Keyes'  Plain  Varicocele  Needle. 

Keyes'  Plain  Varicocele  Needle,  as  illustrated  in  figure  1435,  consists  of 
a  needle  with  a  fixed  handle  and  provided  with  two  eyes  both  in  the  long 
axis  of  the  instrument  and  near  its  point.  When  in  use,  it  is  threaded  with 
two  ligatures,  one  in  each  eye.  The  ends  of  the  posterior  thread  are  tied 
to  form  a  loop,  the  one  in  the  distal  eye  being  permitted  to  hang  loosely 
with  an  equal  portion  upon  each  side  of  the  eye.  After  the  enlarged  veins  are 
isolated,  the  point  of  the  needle  is  pushed  through  the  scrotum  in  close  con- 
tact with  their  posterior  margin.  One  end  of  the  untied  ligature  is  then 
drawn  through  the  tissues  and  held  while  the  needle  is  withdrawn  suffi- 
ciently to  permit  its  point  to  be  carried  in  front  of  the  distended  veins  and 
out  through  the  original  point  of  exit.  The  distal  end  of  the  untied  ligature 
is  then  passed  through  the  advanced  portion  of  the  looped  one  and  drawn 
by  it  through  the  point  of  entrance  to  the  scrotal  tissue;  by  the  complete 
withdrawal  of  the  needle,  the  deposited  ligature  is  then  freed  from  the  scro- 
tal tissues  by  making  one  or  two  sharp  pulls  upon  it,  after  which  it  may  be 
firmly  tied  around  the  veins,  its  free  ends  cut  short  and  the  whole  allowed  to 
disappear  within  the  scrotum. 


Figure  1436.      Keyes'  Improved  Varicocele  Needle. 

Keyes'  Improved  Varicocele  Needle,  as  traced  by  figure  1436,  does  not 
differ  from  the  pattern  of  Reverdin  (shown  in  figure  1151)  except  that  it  is 
straight.  It  is  used  in  the  same  manner  as  the  pattern  of  Whitfield,  pre- 
viously described,  excepting  that  the  open  eye  may  be  employed  to  facili- 
tate the  second  threading. 

Treatment  of  Hydrocele. 

The  treatment  of  this  condition  may  be  palliative  or  operative.  The 
former  may  consist  of  puncture  for  the  release  of  contained  fluids,  trocars  for 
which  are  fully  described  by  figures  377  to  386.  Operative  measures  may 
be  the  injection  of  irritating  fluids  for  producing  adhesive  inflammation  of 
the  sac,  or  incision,  usually  with  removal  of  the  sac. 


SURGERY    OF    THE    SCROTUM    AND    ITS    CONTENTS.  609 

Hydrocele  Injections. 

These  may  be  made  through  a  canula  following  tapping,or  by  hypodermic 
syringes  of  large  size.  Injections  through  a  trocar  canula  maybe  made  with 
any  form  of  syringe.  If  iodine  be  selected  as  a  liquid  for  injection,  the 
syringe  should  be  of  rubber  or  glass.  After  the  trocar  has  been  withdrawn,  a 
short  piece  of  soft  rubber  tubing  may  be  used  to  connect  the  proximal  end 
of  the  canula  with  the  syringe.  The  latter  may  be  either  of  plain  hard  rub- 
ber, or  of  the  pattern  shown  by  figure  1286. 

Injection  by  hypodermic  syringe  may  be  made  with  any  of  the  large 
syringes  shown  on  page  368.  If  a  steel  needle  be  used  in  connection  with 
tincture  of  iodine,  the  needle  should  be  speedily  emptied  and  promptly 
cleansed  to  avoid  oxidation. 

Incision  for  Hydrocele. 

This  procedure  may  be  easily  conducted  with  the  minor  operating  in- 
struments described  on  pages  270  to  275.  The  only  additional  appliance 
required  is  a  suspensory  bandage  shown  on  page  605. 


CHAPTER  XXV. 


SURGERY  OF  THE  MOUTH  AND  THROAT. 

The  various  appliances  required  in  treating  diseases  of  the  mouth  and 
throat  may  be  classified  as  those  for  examinations ;  relief  of  inflammation ; 
uvula;  faucial  /tonsils;  lingual  tonsil;  scarification;  removal  of  foreign 
bodies;  removal  of  tumors;  treatment  of  stricture;  treatment  of  cleft 
palate ;  extraction  of  teeth  and  general  electrical  treatment. 

EXAMINATIONS. 

Examinations  of  the  pharynx  and  larynx  require  a  tongue  depressor  for 
holding  the  tongue  below  the  line  of  vision ;  illuminating  apparatus  and  mir- 
rors for  illuminating  the  parts  to  be  inspected.  To  these  may  be  added  an 
epiglottis  retractor  for  grasping  and  drawing  the  epiglottis  forward. 

In  treating  diseases  of  the  nose,  throat  and  ear,  it  will  be  found  a  con- 
venience if  both  patient  and  operator  are  supplied  with  seats  particularly 
adapted  for  the  work.  These  may  include  a  chair  for  the  patient  and  a 
stool  for  the  operator. 


Figure  1437.    Patient's  Chair.         Figure  1438.    Operator's  Stool.         Figure  1439.    Cuspidor  Holder. 

The  Patient's  Chair,  exhibited  by  figure  1437,  is  supplied  with  a  screw 
base  by  which  the  elevation  of  the  seat  may  be  changed  from  19  to  26 
inches,  thus  suiting  the  requirements  of  various  individuals.  The  back  is 
vertical,  thus  compelling  the  patient  to  remain  within  operating  distance. 
The  back  plat£  is  concave  and  is  supported  by  four  iron  rods  which  furnish 
the  required  rigidity.  In  examinations  of  the  ear,  a  pivotal  seat  is  an  ad- 
vantage as  either  ear  can  be  examined  by  turning  or  swinging  the  patient. 

The  Operator's  Stool,  illustrated  by  figure  1438,  is  provided  with  the 
same  base  and  has  the  same  range  of  vertical  adjustment  as  the  patient's 

610 


TONGUE    DEPRESSORS. 


611 


chair.  The  seat  is  a  trifle  smaller,  being  only  12  inches  in  diameter.  A 
stool  of  this  character  will  be  found  advantageous  in  treating  patients  of  vary- 
ing heights.  Long-legged  patients,  regardless  of  sex,  often  place  the 
operator  at  a  disadvantage.  A  seat  by  the  side  is  not  desirable  in  many 
cases,  a  position  facing  the  patient  being  deemed  essential  by  many  oper- 
ators. If  the  patient  presents  a  pair  of  knees  that  not  only  extend  a  long 
distance  in  front  but  are  flexed  at  a  considerable  height  from  the  floor,  the 
operator  will  have  difficulty  in  securing  a  position  within  "fighting  range" 
unless  he  employs  a  high  stooi.  In  such  cases  Pynchon,  in  a  recent 
article,  claims  that  it  is  of  advantage  to  increase  the  height  of  the  seat 
and  place  the  stool  between  the  knees  of  the  patient,  so  that  when  sitting  on 
the  stool,  he  is  also  over  the  knees  of  the  patient.  The  stool,  being  without 
back,  may  be  mounted  and  dismounted  from  behind. 

The  Cuspidor  Holder,  shown  in  figure  1439,  will  be  found  useful  where 
those  of  the  fountain  variety  are  not  employed.  The  one  shown  in  the  illus- 
tration is  light,  strong,  graceful,  not  easily  tipped  over  and  presents  a  cus- 
pidor at  a  height  where  it  is  convenient  for  the  use  of  the  patient. 

Tongue  Depressors. 

A  tongue  depressor  consists  of  a  retractor  or  spatula- shaped  blade  em- 
ployed to  prevent  the  tongue  from  being  protruded  into  the  line  of  vision 
during  examinations  or  operations.  As  a  rule,  the  use  of  these  instruments 
is  objected  to  by  patients,  particularly  at  the  bedside,  because  of  the  liabil- 


Figure  1440.    Pynchon's  Tongue 
Depressor. 


Figure  1441.    Bosworth's  Tongue 
Depressor. 


Figure  1442.    Frankel's  Tongue 
Depressor. 


ity  of  thus  conveying  disease  from  one  patient  to  another.  Ordinarily,  they 
are  only  employed  in  office  practice  where  they  should  be  thoroughly 
cleansed  after  each  application  to  a  patient.  Bedside  examinations  may 
usually  be  made  with  the  handle  of  a  dessert-  or  tablespoon  without  danger 
of  infection. 

Many  patterns  are  constructed  with  a  hinge  or  joint  that  will  admit  of 
their  being  folded  for  pocket  transportation.  That  these  are  a  source  of 
danger  is  well  known,  and  their  construction  may  be  excused  only  on  the 
ground  that  they  were  designed  to  meet  a  popular  demand.  As  a  matter 


612 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


of  fact,  we  can  not  advise  the  use  of  this  class  of  tongue  depressors.  Many 
patterns  are  fenestrated,  so  that  when  pressed  firmly  upon  the  tongue,  the 
pliable  surface  of  the  latter  bulges  into  the  opening,  thus  furnishing  a  re- 
tracting grip,  that  permits  the  organ  to  be  drawn  forward. 

Bosworth's  Tongue  Depressor,  an  illustration  of  which  is  shown  in  fig- 
ure 1441,  is  one  of  the  simplest,  yet  most  desirable,  patterns  among  this 
class  of  instruments.  The  handle  and  blade,  curved  at  nearly  right  angles 
with  each  other,  are  manufactured  from  a  single  piece  of  steel.  The  handle 
is  serrated  on  both  sides,  to  afford  a  firm  grip.  The  width  of  the  latter  is 
about  ]/?.  an  inch,  while  that  of  the  blade  at  its  widest  part  is  i  inch.  The  latter 
is  fenestrated  near  its  tip,  in  order  to  secure  a  firm  hold  by  forcing  the 
tongue  to  protrude  through  the  opening.  The  handle  and  blade  are  each 
about  4  inches  in  length. 

Frankel's  Tongue  Depressor,  as  shown  by  figure  1442,  is  perhaps  the 
most  slender  and  lightest  model  in  the  market.  The  shape  of  the  blade 
corresponds  quite  accurately  to  the  contour  of  the  tongue  and  chin.  The 
handle  is  attached  to  the  blade  in  such  a  manner  that  when  in  use  it  rests 
partially  underneath  the  chin.  The  blade  is  of  steel  about  ^  of  an  inch  in 
width,  terminating  in  a  loop  or  fenestra  ^  of  an  inch  in  breadth,  while  the 
handle  is  of  brass,  usually  of  a  loop  pattern,  with  a  width  of  ^  of  an  inch. 
The  total  length  of  the  instrument  is  about  9  inches. 

Pynchon's  Tongue  Depressor  consists  of  a  blade  with  two  fenestras,  a 
handle  and  a  finger  ring,  the  whole  manufactured  from  a  single  piece  of 
metal.  Its  general  form  is  well  represented  in  figure  1440.  The  lower  por- 
tion of  the  handle  is  covered  with  coarse  serrations,  and  is  of  such  a  shape  as 
to  furnish  a  firm  and  easy  grip.  The  blade  is  bent  downward  at  slightly 
more  than  a  right  angle. 


Figure  1443.    Tuerck's  Tongue  Depressor. 


Figure  1443A.    Sass'  Tongue  Depressor. 


Tuerck's  Tongue  Depressor,  as  is  made  clear  in  figure  1443,  includes  a 
handle  to  which  may  be  attached  blades  of  various  sizes ;  a  set  of  3  forming 
each  outfit.  The  contact  portion  of  the  blade  consists  of  an  oval  disc, 
concave  and  serrated  upon  the  under  side.  These  discs  are  attached  to 
yoke-shaped  shanks,  the  object  of  which  is  to  bridge  over  the  teeth  and  lips 
and,  at  the  same  time,  form  a  mouth  gag  by  which  the  jaws  may  be  kept 


TONGUE    DEPRESSORS. 


613 


open.  These  shanks  are  attached  to  the  handle  by  a  slip  joint  so  arranged 
as  to  be  easily  separated,  either  when  necessary  to  change  from  one  blade 
to  another  or  for  purposes  of  cleansing.  The  handle  is  of  metal  and  pro- 
vided with  a  long  fenestra  that  it  may  fill  the  hand  and  yet  not  prove  too 
heavy.  The  lower  end  of  the  handle  is  sharply  curved  that  it  may  furnish 
a  resting  place  for  the  little  finger,  thus  preventing  the  hand  from  slipping 
away  from  the  instrument.  The  length  of  the  handle  is  6^  inches,  the  in- 
side distance  of  the  bridge  about  i  y2  inches,  while  the  discs,  three  in  num- 
ber, vary  from  1*4  to  2  inches  in  length.  The  whole  is  so  shaped  that 
when  in  use  the  handle  and  bridge  pass  out  at  one  side  of  the  mouth,  so  that 
the  instrument  does  not  obstruct  the  field  of  vision.  For  office  practice, 
when  it  is  desirable  that  the  patient  should  hold  the  depressor,  this  is  an 
excellent  instrument. 

Sass'  Tongue  Depressor,  as  illustrated  by  figure  I443A,  consists  of  a  plain 
metal  depressor,  the  blade  of  which  is  curved  at  an  angle  of  90°  with  the 
handle.  The  shank  of  the  blade  is  so  shaped  as  to  pass  over  or  around  the 
chin,  the  handle  resting  directly  underneath  the  latter.  When  properly 
constructed,  the  blade  is  of  steel  and  the  handle  either  of  hollow  metal  or 
fenestrated  that  it  may  not  be  fatiguing  to  hold  because  of  its  weight.  The 
length  of  the  blade  to  the  point  of  curvature  is  about  3  inches,  while  the 
entire  length,  including  curves,  is  about  1 1  inches. 


Figure  1444.     Steel  Folding  Tongue  Depressor.        Figure  1444A.     Folding  Wire  Tongue  Depressor. 


The  Plain  Steel  Folding  Tongue  Depressor,  exhibited  by  figure  1444, 
consists  of  two  blades  hinged  so  that  when  opened  the  angle  of  separation 
is  about  125°.  It  is  constructed  from  steel,  is  heavy  and  has  solid  blades. 
The  tip  of  one  of  the  blades  is  convex,  while  the  other  is  square  with 
rounded  corners.  The  under  surface  of  each  is  roughened  or  creased,  that 
they  may  furnish  good  .retracting  surfaces.  The  width  of  the  blades  is 
about  i  inch,  while  their  length  is  about  3  inches. 

The  Folding  Wire  Tongue  Depressor,  as  shown  by  figure  1444 A,  consists 
of  two  blades  of  heavy  wire  joined  by  strong  hinges.  One  blade  is  a  plain 
loop  4  inches  in  length  and  5/8  of  an  inch  in  breadth ;  the  other  is  of  the  same 
length,  but  i  inch  in  breadth,  is  expanded  at  its  tip  to  a  breadth  of  i  %  inches 
and  curved  like  the  letter  "M"  with  rounded  angles.  This  instrument  is 
strong  in  construction,  of  good  size,  and,  for  a  folding  instrument,  a  desirable 
pattern. 


Figure  1445.     Glass  Plate  Tongue  Depressor. 

The  Glass  Plate  Tongue  Depressor,  as  defined  by  figure  1445,  is  a  plain 
piece  of  glass  about  i  inch  in  breadth,  7  inches  in  length  and  curved  at  its 
center  in  bayonet  form.  It  is  employed  by  some  specialists  because  of  the 
ease  with  which  it  may  be  cleansed. 


614  SURGERY    OF    THE    MOUTH    AND    THROAT. 

Illuminating  Apparatus. 

As  nearly  the  same  list  of  illuminating  appliances  are  applicable  to  ex- 
aminations of  the  naso-pharynx,  nose  and  ear,  reference  will  also  be  made 
to  their  use  for  these  purposes.  The  apparatus  necessary  usually  consists 
of  light;  reflector  for  directing  the  light  rays  into  the  cavity,  and  intra-cav- 
ity  mirror,  for  illuminating  parts  without  the  line  of  direct  vision. 

Light  suitable  for  such  illumination  may  be  obtained  from  the  following 
sources: 

Natural  light  (daylight) ;  carbon  oil  lamps ;  ordinary  gas  burners  and 
brackets;  acetylene  gas  and  electricity. 

All  of  these  may  be  used  either  direct  or  by  reflection. 

Natural  Light. 

This  may  be  employed  either  in  the  form  of  direct  solar  rays  or  diffused 
light.  The  latter,  when  properly  manipulated,  furnishes  a  bright  and  natu- 
ral illumination,  the  shades  and  colors  showing  correctly. 

A  single  window  and  a  north  exposure  will  furnish  a  satisfactory  light 
on  a  bright  day,  provided  the  patient  be  placed  with  his  back  to  the  window 
and  the  light  be  reflected  with  a  mirror  having  a  long  focus,  say  of  12  to  14 
inches.  In  fact,  a  mirror  of  long  focus  must  be  employed  in  all  cases  where 
the  rays  of  light  to  be  reflected  are  parallel  or  diffused.  Better  results  will 
be  obtained  if  the  walls  of  the  room  are  white,  that  the  diffused  light  may 
be  as  brilliant  as  possible. 

Politzer  particularly  recommends  diffused  daylight  in  ear  examinations 
that  the  shades  and  color  of  the  membranum  tympani  may  be  more 
naturally  observed  and  determined.  The  direct  sun's  rays  for  this  pur- 
pose are  too  dazzling  and  hence  are  not  often  employed. 

Sunlight  may  be  utilized  to  advantage  in  some  cases,  provided  it  be  ad- 
mitted to  the  room  in  a  small  beam  and  this  reflected  by  a  mirror,  the  same 
as  employed  for  diffused  light.  Care  must  be  taken,  however,  to  avoid 
burning  the  patient  by  concentration  of  the  rays. 

Carbon  Oil  Lamps  and  Burners. 

Among  the  many  devices  in  this  line  of  mechanics,  none  have  given 
more  universal  satisfaction  for  surgical  use  than  the  Argand  burner.  As 
they  are  adapted  for  both  oil  and  gas,  they  are  suited  to  the  wants  of  both 
the  specialist  and  the  general  practitioner.  As  the  flame  is  circular  in  form 
and  more  compact  in  proportion  to  its  density  of  light  power  than  the  flat 
flame,  it  is  better  adapted  for  use  either  direct  or  with  condensing  lenses 
or  reflectors. 

The  Student's  Lamp  with  Argand  Burner,  as  depicted  in  figure  1446, 
differs  from  the  student's  lamp  commonly  found  in  the  market,  in  being 
provided  with  an  extra  heavy  base,  so  that  it  may  not  be  easily  overturned. 

By  means  of  a  set-screw,  the  lamp  may  be  fixed  at.  any  desired  height. 
The  globe. and  the  support  which  holds  it  may  be  removed  and  a  condenser 
may  be  attached,  as  the  same  pocket  that  is  utilized  for  a  globe  support 
will  hold  a  condenser. 

Brackets. 

These  are  utilized  both  for  the  support  of  lamps  and  of  gas  burners,  the 
former  being  seldom  employed.  One  form  of  bracket  suitable  for  this  pur- 
pose, however,  is  shown  in  connection  with  figure  1457.  Those  employed 
with  gas  are  of  two  varieties ;  those  arranged  for  the  gas  to  pass  directly 
through  the  bracket  arms  and  joints,  and  those  designed  to  support  a  flex- 


ILLUMINATING    APPARATUS. 


615 


ible  rubber  tube,  the  latter  conveying  the  gas  to  the  burner.  If  well  con- 
structed, the  former  are,  as  a  rule,  more  satisfactory  and  are  generally  pre- 
ferred. 

Bishop's  Gas  Bracket,  as  traced  in  figure  1447,  consists  of  an  adjustable 
arm  having  a  perpendicular  range  of  2  feet  and  a  radius  of  any  distance 
within  3  feet.  By  this  we  mean  that  by  flexing  the  arm  at  the  joint  corres- 
ponding with  the  elbow,  the  light  may  swing  close  to  the  central  point,  or 


Figure  1446.     Student's  Lamp  with 
Argand  Burner. 


Figure  1447.    Bishop's  Gas  Bracket. 


when  fully  extended,  it  covers  a  swinging  range  3  feet  from  the  center. 
It  is  maintained  in  any  desired  position  by  a  brake,  so  adjusted  that  it  will 
"set"  automatically.  To  change  the  height  of  the  light  it  is  necessary  only 
to  release  the  brake  by  thumb  and  finger  pressure  and  move  the  apparatus 
to  the  point  desired.  Gas  is  conducted  to  the  burner  by  means  of  a  rubber 
hose.  It  can  also  be  arranged  for  use  with  an  oil  lamp. 


Figure  1448.    Philadelphia  Gas  Bracket. 


The  Philadelphia  Gas  Bracket,  as  is  made  clear  in  figure  1448,  consists 
of  a  double  arm,  jointed  in  such  a  manner  that  it  may  be  swung  in  any 
direction  and  raised  or  lowered  to  different  heights.  The  amount  of  eleva- 
tion secured  may  be  maintained  by  means  of  a  suitable  locking  device  con- 
trolled by  milled  nuts.  This  bracket  may  be  attached  to  a  fixed  gas  pipe, 
one  that  projects  only  a  short  distance  from  the  wall  being  preferred.  The 


616  SURGERY    OF    THE    MOUTH    AND    THROAT. 

length  of  the  bracket  when  fully  extended  is  25  inches,  while  its  perpen- 
dicular range  is  about  15  inches.  It  is  so  constructed  that  the  burner  is 
always  in  a  vertical  position  without  regard  to  the  height  of  the  lamp. 

Acetylene  Gas. 

Acetylene  gas  is  produced  by  bringing  water  into  contact  with  calcium 
carbide.  The  latter  is  the  product  of  the  electrical  fusion  of  lime  and  coke. 
It  is  claimed  that  its  cost  is  less  than  one  half  that  of  coal  gas,  that  it  gives 
off  but  little  heat,  burns  freely,  needs  no  chimney  and  forms  no  soot.  With 
this  gas,  the  largest  and  smallest  units  of  light  are  the  same  in  color  and  do 
not  deteriorate.  The  gas  in  itself  is  not  explosive,  and  when  mixed  with 
twelve  parts  of  air,  it  possesses  the  same  properties  as  coal  gas. 

Lamps  burning  this  gas  are  being  made  and  sold,  particularly  for 
physicians'  and  surgeons'  use.  They  may  be  placed  on  a  bracket  for  office 
use  or  may  be  jointed  and  portable,  that  they  may  be  carried  in  the  pocket 
or  in  the  surgeon's  case.  A  lamp  of  small  size  will  give  a  light  as  white 
as  electricity  and  equal  to  a  4o-candle  power  lamp.  They  give  promise  of 
meeting  every  require'ment  of  the  physician  and  surgeon. 

Electric  Laryngoscopes. 

Appliances  designed  to  utilize  electric  light  have  been  constructed  in  vary- 
ing designs,  all  intended  to  illuminate  the  natural  body  cavities.  As  a  rule, 
they  have  proved  unsatisfactory  because  of  their  limited  application  and 
lack  of  reliability.  The  latter  is  due  largely  to  imperfect  electrical  appara- 
tus, the  result  being  that  frequently,  when  wanted  for  use,  the  battery  or 
current  is  found  to  be  out  of  order.  Many  devices  consisting  of  a  small 
lamp  fixed  upon  the  end  of  a  slender  handle,  and  intended  for  throat  ex- 
aminations, have  been  placed  upon  the  market,  but  so  far  as  we  are  able  to 
learn  they  are  not  satisfactory,  and  are  seldom  employed  by  specialists. 


Figure  1419.     Electric  Laryngoscope. 


The  Electric  Laryngoscope,  exhibited  in  figure  1449,  comprises  a  Fox's 
head-band,  as  shown  in  figure  1465,  and  an  electric  lamp  combined  with 
a  condenser  which  furnishes  divergent  rays.  It  consists  of  a  cylinder  tele- 


ILLUMINATING   APPARATUS. 


617 


scoping  from  \y2  to  2  inches  in  length,  5/8  of  an  inch  in  diameter  and  pro- 
vided with  two  suitable  lenses.  If  connected  with  a  proper  current,  this 
instrument  will  throw  a  brilliant  white  light  of  6  to  8-candle  power.  It  is 
so  arranged  that  it  may  be  removed  from  the  head  band  and  utilized  for  ex- 
amining any  of  the  cavities  of  the  body. 


Figure  1450.    Electric  Head  Lamp. 


Figure  1451.     Lamp  Rheostat  and  Illuminator. 


The  Electric  Head  Lamp,  set  forth  in  figure  1450,  consists  of  an  elec- 
tric light  enclosed  within  a  funnel-shaped  reflector  by  which  divergent 
rays  may  be  projected  upon  the  operating  field.  Two  patterns  are  sup- 
plied, one  fixed,  the  other  with  ball  and  socket  joint,  so  that  it  may  be 
turned  in  any  desired  direction.  Connection  with  a  battery  or  a  street  cur- 


Figure  1452.    Electric  Illuminating  Outfit. 


rent  may  be  effected  by  a  double-conducting  cord  passing  over  the  head  of 
the  surgeon. 

As  the  apparatus  has  no  lenses  and  no  complicated  mechanism,  it  is  light 
and  portable.     It  is  supplied  with  a  switch,  by  means  of  which  the  current 


618 


SURGERY    OF    THE    MOUTH    AND    THROAT. 


is  controlled.  It  may  be  procured  with  lamps  of  6  to  3  2 -candle  power,  the 
selection  of  course  depending  upon  the  character  of  the  work  required. 

The  Lamp  Rheostat  and  Illuminator,  exhibited  in  figure  1451,  may  be 
connected  with  an  incandescent  system,  the  rheostat  serving  to  regulate  the 
current.  The  small  lamp  exhibited  in  the  illustration,  is  mounted  on  a 
cylindrical  handle  by  which  it  may  be  passed  within  the  mouth  or  other 
natural  or  artificial  cavity.  In  his  order,  the  physician  should  state  the 
voltage  of  the  current  with  which  it  is  to  be  used. 

The  Electric  Illuminating  Outfit,  exhibited  in  figure  1452,  includes  a 
series  of  dry  cells  similar  to  those  described  by  figure  433,  contained  within 
a  hardwood  box  9  by  9  by  8  inches.  The  cells  are  attached  to  a  lo-point  switch 
by  which  the  brilliancy  of  the  lamp  may  be  regulated.  The  latter  consists 
of  a  small  incandescent  light  attached  to  a  tubular  shaft  and  connected  to 
the  battery  by  suitable  conducting  cords.  A  push  button  and  double  cord, 
also  connected  with  the  battery,  enable  the  physician  to  switch  the  current 
on  and  off,  as  desired.  The  light  is  adapted  for  making  examinations  in 
almost  any  of  the  larger  cavities  of  the  body. 

Condensers. 

Rays  of  light  may  issue  from  the  generating  apparatus  either  parallel, 
condensed  or  divergent,  according  to  the  form  and  location  of  the  lens  em- 
ployed. 

Purchasers  and  dealers,  as  a  rule,  have  paid  too  little  attention  to  the 
construction  and  mounting  of  condensing  lenses,  the  result  being  that  many 
are  in  use  whose  focus  is  in  front  of  or  beyond  the  point  of  inspection.  As 
the  point  of  focus  depends  partially  on  the  concavity  of  the  reflector,  the 
best  results  can  be  obtained  only  when  all  conditions  are  thoroughly  under- 


Figure  1453.    Mackenzie's  Condenser.    Figure  1454.  Bishop's  Reflector.    Figure  1455.  Brown's  Reflector. 


stood  and  perfectly  adjusted.  The  surgeon  should  determine  by  a  series  of 
experiments  whether  or  not  the  combination  of  lenses  and  reflectors  in  use 
by  him  is  suitable  for  the  purpose  employed. 

Condensing  lenses,  while  not  necessary,  serve  to  increase  the  brilliancy 
of  the  illumination  by  focusing  a  larger  number  of  rays  on  the  part  under 
inspection.  As  usually  mounted,  they  also  act  as  a  shield  protecting  the 


ILLUMINATING    APPARATUS. 


619 


eyes  of  the  operator  from  the  confusing  sensation  that  would  be  produced 
were  they  exposed  to  the  action  of  a  bright  flame  in  close  proximity,  the 
effect  of  which  would  be  to  contract  the  pupils,  dazzle  the  vision  and  de- 
crease the  light-perceiving  power.  The  location  of  the  lens  with  reference 
to  the  flame  is  a  matter  of  considerable  importance.  If  the  flame  be  located 
directly  in  the  focus  of  the  lens,  the  rays  of  light  issuing  from  the  latter  (if 
single)  will  be  parallel.  If  it  be  within  the  focus,  they  will  still  be  divergent, 
although,  of  course,  to  a  lesser  degree  than  those  that  do  not  pass  through 
the  lens,  while  if  the  flame  be  placed  without  or  beyond  the  focal  distance, 
the  rays  will  converge. 

Mackenzie's  Condenser,  as  portrayed  by  figure  1453,  is  probably  the  best 
known  among  this  class  of  appliances.  It  consists  of  a  cylindrical  body  2^ 
inches  in  diameter  by  8  inches  in  height,  upon  one  side  of  which  is  a  T-- 
shaped extension  or  opening,  in  the  end  of  which  the  lens  is  located.  The 
lens  is  usually  about  2^4  inches  in  diameter,  planh-convex,  with  a  focal  dis- 
tance of  about  $l/2  inches,  while  the  distance  from  the  center  of  the  flame  to 
the  lens  is  about  2^  inches.  This  furnishes  diverging  rays.  By  substitut- 
ing a  lens  having  a  2^ -inch  focus,  parallel  rays  may  be  projected. 

Bishop's  Reflector,  as  will  be  seen  by  referring  to  figure  1454,  consists 
of  a  plain  metallic  cylinder  or  chimney  2^  inches  in  diameter,  provided 
with  a  cross-section  or  "T"  for  light  projection.  The  latter  portion  extends 
about  y2  an  inch  to  the  rear  of  the  upright  tube,  the  end  or  back  being  in  the 


Figure  140(i.    .Bucket's  Condenser  Reflector 
Holder  and  Adjustable  Stand. 


Figure  1457.    Boekel's  Condenser  with  Student 
Lamp  and  Wall  Bracket. 


form  of  a  concave  metal  reflector.  The  opposite  portion  or  light  chamber 
is  \yz  inches  in  length  and  without  lens.  The  instrument  is  therefore  a  re- 
flector and  not  a  condenser.  When  used  with  a  burner  of  good  light-giving 
power,  it  furnishes  a  satisfactory  instrument. 

Brown's  Reflector,  as  sketched  in  figure  1455,  is  made  from  a  tube  about 
2^  inches  in  diameter,  two-fifths  of  the  circumference  of  which  is  cut  away, 
excepting  a  small  strip  at  its  lower  border.  The  inner  surface  of  the  cen- 
tral horizontal  zone  is  highly  polished,  so  that  it  acts  as  a  concave  re- 
flector and  serves  as  a  shield  for  the  eye  of  the  operator.  Where  a  con- 
denser is  not  desired  this  furnishes  a  satisfactory  instrument  in  a  simple 
and  inexpensive  form. 


620 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


Boekel's  Condenser,  Reflector  Holder  and  Adjustable  Stand,  as  drawn 
in  figure  1456,  consists  of  a  chimney  and  lens  to  be  employed  with  an  Ar- 
gand  burner  that  may  be  used  with  carbon  oil  or  g-as.  The  rear  of  the 
chimney  is  supplied  with  a  reflector,  in  order  that  the  illumination  may  be 
intensified.  This  may  be  used  either  with  or  without  a  mirror  bar.  The 
latter  consists  of  a  telescoping  bracket  attached  to  the  chimney,  forming  the 
tube  of  the  condenser.  This  attachment  is  made  by  a  collar  passing  around 
the  chimney,  to  the  opposite  side  of  which  a  similar  but  shorter  rod  is  at- 
tached, whose  end  is  supplied  with  a  metallic  ball  of  sufficient  size  to  coun- 
terbalance the  weight  of  the  mirror  and  its  support.  A  locking  device  is 
provided,  by  which  the  mirror  may  be  fixed  so  as  to  rest  exactly  within  the 
beam  of  light. 

The  mirror  is  attached  to  the  bracket  bar  by  a  ball  and  socket  joint,  that 
it  may  be  turned  to  any  desired  angle.  The  lens  is  2^5  inches  in  diameter  and 
of  2  -inch  focus.  It  is  located  i  ^  inches  from  the  center  of  the  flame,  thus 


Figure  1458.     Devilbiss'  Condenser. 

furnishing  diverging  rays.  The  condenser  may  be  procured  either  with  or 
without  the  mirror  or  mirror  bar.  The  bracket  is  of  the  pattern  shown  by 
figure  1467.  The  adjustment  is  such  that  the  condenser  may  be  placed  at 
any  desired  "height.  The  flexible  tube  shown  in  the  illustration  is  intended 
for  connection  with  a  gas  jet. 

Boekel's  Condenser  with  Students'  Lamp  and  Wall  Bracket,  as  detailed 
in  figure  1457,  includes  a  condenser,  mirror  bar  and  mirror  like  those  last 
described.  The  principal  change  consists  in  the  substitution  of  a  student's 
lamp  for  a  gas  burner  and  the  arrangement  of  the  lamp  upon  a  portable  rod 
or  wall  bracket,  so  adjusted  that  by  means  of  a  set  screw  the  apparatus  may 
be  placed  at  any  desired  height.  As  the  appliance  may  be  rotated  upon  the 
bracket,  both  vertical  and  lateral  motion  are  furnished. 

Devilbiss'  Condenser,  which  is  shown  in  figure  1458,  is  a  modification  of 
the  Mackenzie  pattern,  combining  some  of  the  principles  exhibited  in  the 
device  of  Tobold.  While  particularly  designed  for  use  with  a  student's 


ILLUMINATING  APPARATUS. 


621 


lamp,  it  may  be  used  with  gas.  It  consists  of  a  short  cylindrical  flame 
chamber  to  one  side  of  which  the  lens-bearing  tube  is  attached.  The  lens 
is  bi-convex,  3  inches  in  diameter  with  a  4-inch  focus  and  located  $$/%  inches 
from  the  center  of  the  flame,  thus  furnishing  divergent  rays.  A  plain  mir- 
ror bar  is  attached  to  the  upper  surface  of  the  lens  tube.  This,  when  ar- 
ranged according  to  the  ideas  of  its  inventor,  is  supplied  with  a  concave 
reflector  and  a  plain  circular  mirror,  both  attached  by  ball  and  socket  joints, 
so  that  they  may  be  placed  in  any  position.  By  so  locating  the  plain  mirror 
that  the  reflection  of  the  parts  under  inspection  may  be  observed  by  the 
patient,  the  latter  may  be  made  acquainted  with  such  conditions  as  the 
operator  may  wish  to  explain. 

It  is  argued  that  by  this  method  patients  may  often  be  made  acquainted 
with  the  extent  and  nature  of  diseased  conditions,  and  thus  induced  to  re- 
ceive treatment,  while  otherwise  they  would  not  consider  the  affection  of  suf- 
ficient importance  to  demand  medical  assistance.  If  deemed  advisable,  the 
patient  may,  from  time  to  time,  be  shown  the  changing  condition  of  the 
diseased  tissues  and  thus  kept  interested  in  the  treatment.  In  some  re- 
spects this  is  an  improvement  on  such  devices  as  employ  a  fixed  bracket, 
because  the  patient  may  be  instructed  and  soon  learn  to  keep  himself  "in 
light." 

This  apparatus  is  not  as  easily  overturned,  as  would  appear  from  the  illus- 
tration, because  not  only  is  the  lamp  usually  supplied  with  an  extra  heavy 
base,  but  the  oil  reservoir  located  on  the  side  opposite  from  the  condenser 
serves  to  counterbalance  the  weight  of  the  latter. 


Figure  1459.    Tobold's  Condenser. 

Tobold's  Condenser,  as  illustrated  in  figure  1459,  is  a  combination  of 
three  lenses,  which,  as  usually  constructed  and  as  found  in  the  market,  fur- 
nishes only  a  confusion  of  well-known  scientific  principles ;  in  fact,  it  has 
been  shown  by  Weil  that  the  instrument  is  improved  by  removing  one,  or 
even  two,  of  its  lenses.  The  apparatus  is  more  complicated  than  any  other 
pattern,  and,  so  far  as  we  can  learn,  possesses  no  especial  advantages.  It 
is  provided  with  a  long-jointed  bracket  for  holding  the  mirror,  so  arranged 
that  it  can  be  moved  to  the  right  or  left  and  accommodated  to  the  wants  of 


622  SURGERY    OF    THE    MOUTH    AND    THROAT. 

the  operator.      The  different  parts  can  be  attached  to  a  student's  lamp  or  an 
Argand  gas  burner,  with  either  of  which  it  will  give  a  powerful  light. 

Any  of  these  condensers  may  be  used  in  connection  with  gas'  or  they 
may  be  attached  to  lamps.  They  may  be  arranged  in  the  form  of  upright 
stands  or  used  with  adjustable  arms  or  brackets. 

Reflectors. 

Light  for  examinations  may  be  used  either  direct  or  with  reflecting 
mirrors.  By  the  use  of  the  latter,  the  surgeon  is  enabled  to  place  the  light 
in  a  more  convenient  position,  and  they  also  assist  in  securing  a  brighter 
illumination  by  a  concentration  of  the  light  rays. 

Direct  light  necessitates  placing  the  lamp  or  other  generator  imme- 
diately in  front  of  or  in  a  line  with  the  long  axis  of  the  cavity  to  be 
inspected.  This  is  not  only  awkward,  but  obstructs  the  field  of  direct 
vision.  When  it  is  necessary  to  use  such  a  light,  a  shield  should  be  inter- 
posed between  the  flame  and  the  eye  of  the  surgeon.  The  only  exception 
to  this  is  in  the  use  of  electric  lights,  which,  as  shown  by  figure  1450,  are 
generally  used  upon  the  forehead  and  in  combination  with  a  projecting 
lens. 

Reflectors  are  circular,  usually  concave  mirrors,  provided  with  round 
central  apertures,  from  7  to  8  millimeters  in  diameter,  through  which  the 
operator  may  inspect  the  illuminated  parts.  The  point  of  observation  is, 
therefore,  in  the  center  of  the  projected  cone  of  light.  They  may  be 
obtained  of  either  mirror  glass  or  polished  metal.  The  latter  is  now  but 
little  employed.  For  throat  examinations  these  reflectors  are  attached  to 
head-bands  or  fixed  brackets  by  means  of  joints,  those  of  the  ordinary  ball 
and  socket  pattern,  because  they  admit  of  motion  in  almost  any  direction, 
being  preferred.  The  knob  or  ball  forming  a  portion  of  this  joint  is  usually  at- 
tached to  the  mirror  by  a  short  post  about  y2  an  inch  in  length.  Ingals  advises 
that  this  post  and  knob  be  placed  ife  inches  from  the  center  of  the  mirror, 
claiming  that  when  attached,  and  the  head-band  in  position,  the  central  open- 
ing of  the  mirror  will  be  opposite  the  pupil  of  the  eye  of  the  average  oper- 
ator. Politzer,  on  the  other  hand,  uses  a  small  mirror  and  a  head-band 
that  rests  higher  on  the  forehead,  adjusting. the  knob  to  the  rim  of  the 
mirror,  so  that  it  rests  in  the  same  plane  with  the  mirror  face,  claiming 
that  by  so  doing  a  greater  range  of  motion  is  secured.  The  proper  size  of 
mirror  to  be  employed  will  depend  on  the  form  of  light  and  character  of 
the  condensing  lens,  if  any,  with  which  it  is  to  be  used.  Generally  mirrors 
of  3  to  3 YI  inches  in  diameter  are  preferred,  but  those  zy2  (Politzer)  and  4 
inches  (Ingals)  in  diameter  are  sometimes  advised.  One  advantage 
claimed  for  a  large  mirror  is  that  it  shades  from  the  light  the  eye  not  in 
use  by  the  operator. 

Small  mirrors  can  be  used  advantageously  only  in  connection  with 
lenses  that  furnish  converging  rays,  for  otherwise  a  portion  of  the  reflected 
rays  would  be  lost.  Where  parallel  rays  are  secured,  a  reflector  may  be 
employed  whose  diameter  is  the  same  as  that  of  the  condensing  lens.  The 
reflector,  however,  in  this  case,  should  have  a  focus  corresponding  to  the 
distance  between  the  mirror  and  the  part  to  be  inspected. 

If  the  rays  of  light  are  converging,  the  reflector  may  be  smaller  than 
the  lens,  but  with  a  long  focal  distance.  If  the  rays  are  diverging,  the 
mirror  should  be  larger  than  the  lens,  that  none  of  the  rays  may  be  lost, 
and  with  a  short  focal  distance,  that  their  separation  may  be  counteracted 
and  the  beam  focused. 


ILLUMINATING    APPARATUS.  623 

Large  mirrors,  however,  possess  the  disadvantage  of  extra  weight. 
Politzer  advises  the  use  of  a  mirror  2^  inches  in  diameter,  that  it  may  be 
carried  in  the  vest  pocket. 

In  order  to  obtain  the  best  results  it  is  necessary  that  the  rays  of  light 
projected  by  the  reflector  should  focus  on  the  part  under  examination. 
Although  much  has  been  written  concerning  the  proper  focal  distance  of 
the  reflector,  little  attention  is  still  being  paid  to  the  subject  by  the 
average  purchaser  and  dealer. 

The  focus  of  the  mirror  should  correspond  in  each  case  with  the  nature 
of  the  work  to  be  performed  and  the  appliances  to  be  used  with  it. 

The  rays  from  artificial  light  are  divergent  unless  modified  by  lenses. 
A  brilliant  illumination  from  such  a  source  can  be  obtained  only  by  chang- 
ing the  beam  into  a  convergent  one.  This  may  be  accomplished  by  the 
use  of  a  proper  reflector.  Surgeons  who  have  been  disappointed  in  obtain- 
ing good  illumination  may  profit  by  a  careful  study  of  the  laws  of  optics 
that  govern  this  subject.  Rays  may  frequently  be  corrected  by  simply 
changing  the  distance  from  the  light  to  the  reflector,  or  from  the  reflector 
to  the  point  of  observation. 

Examination  of  the  ear  may  require  a  reflector  with  a  focal  distance  of 
not  more  than  3  to  4  inches,  while  for  examination  of  the  throat  and 
trachea  at  its  bifurcation,  a  reflector  with  a  focus  of  15  to  1 6  inches  would 
be  required  if  diffused  light  were  used.  The  focal  distance  of  the  reflector 
should  be  known  to  the  operator,  and  the  instrument  dealer  should  be  pro- 
vided with  an  assortment  of  various  focal  strengths. 

The  position  occupied  by  the  reflector  with  reference  both  to  the  patient 
and  the  flame  must  be  such  that  the  best  illumination  possible  may  be 
secured.  For  instance,  with  parallel  rays  from  a  condenser  or  diffused 
light,  if  the  reflector  be  of  long  focus,  say  one  of  15  inches  and  the  glottis 
of  an  adult  male  be  under  inspection,  the  reflector  should  be  stationed  about 
nine  inches  in  front  of  the  patient's  lips.  Allowing  three  inches  from  the  lips 
to  the  surface  of  the  throat  mirror  and  three  from  the  throat  mirror  to  the 
glottis,  the  latter  would  be  in  the  exact  focus  of  the  reflector. 

The  distance  of  the  flame  from  the  reflector  is  also  an  important  factor 
in  the  adjustment  of  the  focal  distance.  It  is  evident  that  as  this  distance 
increases,  the  rays  become  more  nearly  parallel,  and  in  proportion  as 
this  distance  is  lengthened  the  concavity  or  focusing  power  of  the  reflector 
is  decreased. 

A  reflector,  then,  that  is  too  short  in  its  focal  distance  for  practical  use 
may  be  improved  by  decreasing  the  distance  from  it  to  the  flame;  and  on 
the  same  principle,  one  with  too  long  a  focal  distance  may  be  shortened  by 
placing  the  light  farther  away. 

Ordinarily,  the  operator  may  employ  a  reflector  with  a  focus  of  about  8 
inches,  placing  the  light  nearly  on  a  level  with,  and  as  far  distant  as  the 
patient's  ear.  A  proper  lens  or  condenser  will  insure  greater  intensity, 
although  it  should  not  be  so  powerful  that  its  rays  will  not  diverge.  Such 
a  combination  should  produce  a  suitable  focus  at  a  distance  of  about 
12  inches  from  the  reflector. 

Such  a  reflector  can  be  utilized  for  nearly  all  the  uses  required  in  sur- 
gery. For  instance,  if  employed  with  a  condenser  having  a  focal  distance 
of  3^  inches,  located  2^  inches  from  the  center  of  the  flame,  the  rays  of 
light,  if  divergent  and  thrown  upon  a  reflector  with  an  8-inch  surface, 
would  come  to  a  focus  about  12  inches  from  the  reflector. 

If  the  operator  succeeds  in  obtaining  an  exact  focus  on  the  part  tinder 


624 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


inspection,  he  will  secure  the  further  advantage  of  the  illumination  offered 
within  the  fields  of  the  circles  of  dispersion.  These  are  two  in  number, 
one  just  within  or  in  front  of  the  focal  point,  the  other  without  or  beyond 
it.  These  circles  with  an  ordinary  reflector  extend  about  y2  an  inch  each  way 
from  the  focal  plane,  affording  within  this  distance  nearly  as  bright  a  light 
as  in  the  center.  On  a  surface  approximately  flat,  this  may  be  of  no 
advantage,  but  in  examination  of  tubular  cavities  it  is  of  value. 

The  rays  of  light  leaving  the  generator  are  projected  with  or  without  a 
condenser  against  the  reflector,  from  this  to  the  throat  mirror,  and  thence 
to  the  illuminated  part.  From  these  surfaces  the  rays  not  absorbed  return 
as  visual  rays,  following  the  same  reflected  lines  as  when  passing  outward, 
thus  demonstrating  the  necessity  for  locating  the  eye  directly  in  the  center 
of  both  the  out-going  and  returning  beam.  It  will  readily  be  seen  that 
mirrors  placed  above  or  to  one  side  of  the  eye,  or  on  a  fixed  bracket,  do 
not  offer  this  advantage. 


Fijrure  1460.    Ingals'  Reflector  with  Lens  for 
Correcting  Defective  Accommodation. 


Figure  1461.     Showing  Noltenius'  Demon- 
strating Mirror. 


Ingals'    Reflector   with   Lens    for    Correcting     Defective   Accommodation, 

as  represented  in  figure  1460,  consists  of  an  ordinary  4-inch  reflector  with 
an  8-inch  focus,  to  the  back  of  which  a  small  lens  is  attached  by  a  hinged 
joint.  This  lens  is  held  in  place  by  a  semi-circular  clip  so  adjusted  that  it 
may  be  thrown  over  the  central  opening  in  the  reflector  or  turned  away 
when  not  required  for  use. 

This  lens  does  not  magnify  the  parts  under  inspection  as  has  been  sup- 
posed, but  is  intended  to  correct  defective  accommodation,  or  in  special 
cases,  errors  of  refraction  in  the  eye  of  the  operator.  The  head-band 
should  be  of  strong  non-elastic  webbing  of  the  Schroeder  pattern  and 
should  have  a  firm  nasal  rest. 

Noltenius'  Demonstrating  Mirror,  as  it  appears  in  figure  1461,  consists 
of  a  small  keystone-shaped  mirror  that  may  be  attached  to  the  front  of  an 
ordinary  reflector  by  means  of  a  spring  or  clamps  adjusted  to  head-mirrors 


ILLUMINATING   APPARATUS. 


625 


of  varying  sizes.  The  arrangement  of  the  small  mirror  is  such  that  its  faoe 
presents  an  angle  of  about  30°  with  that  portion  of  the  face  of  the  mirror 
over  which  it  rests.  If  it  be  properly  adjusted,  it  may  be  used  to  exhibit 
to  an  assistant  or  pupil  the  condition  of  the  parts  under  inspection. 

Reflector  Holders. 

Various  methods  are  employed  for  holding  a  reflector  while  in  use. 
They  consist  either  of  a  head-band  adjusted  to  and  arranged  to  move  with 
the  head  of  the  operator,  some  form  of  a  movable  bracket  that  may  be 
fixed  in  any  desired  position,  or  a  plain  handle.  Head-bands  are  con- 
structed with  a  tape  or  spring  that  encircles  the  head.  They  vary  in 
construction  from  the  ordinary  tape  encircling  the  head  on  a  line  with  the 
forehead  to  the  metallic  bands  that  pass  over  the  head  antero-posteriorly. 
Usually  they  are  of  as  light  construction  as  possible,  for  otherwise  they 
become  burdensome  if  worn  for  any  length  of  time,  particularly  when  the 
weight  of  the  reflector  is  added. 

Reflectors  for  aural  use  should  be  provided  with  plain,  straight  handles, 
attached  by  a  screw  joint;  they  are  convenient  for  ordinary  examinations. 
The  American  pattern  without  regard  to  size  or  focus  is,  we  believe,  sup- 
plied with  these  handles,  an  illustration  of  which  is  shown  in  connection 
with  figure  1464. 


Figure  1462.     Kramer's  Head-band. 


Figure  1463.    Schroetter's  Head-band. 


Kramer's  Head-band,  as  explained  by  figure  1462,  is  of  the  ordinary 
pattern  and  consists  of  a  tape  or  band  for  encircling  the  head.  In  the 
center  of  this  a  metallic  strip  with  rounded  ends  is  fastened  by  means  of 
strong  threads  passed  through  holes  provided  for  that  purpose  The 
under  surface  of  the  metallic  portion  is  usually  padded  that  it  maybe  ren- 
dered more  comfortable  when  pressed  against  the  brow  of  the  operator. 
The  mirror  is  attached  by  two  hinged  arms,  regulated  by  a  set  screw. 
The  inner  surfaces  of  the  distal  ends  of  these  arms  form,  when  pressed 
together,  a  socket,  which,  when  clasped  around  the  ball  of  the  reflector, 
furnishes  what  is  known  as  a  ball  and  socket  joint,  by  the  use  of  which  the 
reflector  may  be  securely  held  at  any  desired  angle. 

Formerly  these  tapes  were  manufactured  from  elastic  material,  but  the 
better  grades  are  now  constructed  from  firm  and  non-elastic  ribbon. 
Usually  they  are  about  i  inch  in  width.  That  they  may  be  as  light  as 
possible,  the  head-band  plates  are  frequently  manufactured  from  aluminum. 

Schroetter's  Head-band,  as  set  forth  in  figure  1463,  differs  from  the 
pattern  of  Kramer  principally  in  being  constructed  with  a  double  nasal 
rest,  that  it  may  remain  more  securely  in  proper  position.  The  ball  and 
socket  joint  consists  of  two  pieces,  one  fixed,  the  other  movable,  both 

40 


626 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


being  regulated  by  a  set  screw.  This  pattern  is  usually  manufactured 
with  tape  i  y(  inches  wide,  and  is  much  more  satisfactory  than  the  plain 
design  previously  referred  to. 


Figure  1464.    Sajous'  Head-band. 

Sajous'  Head-band,  as  shown  in  figure  1464,  differs  from  the  pattern  of 
Kramer  principally  in  the  construction  of  the  arms  that  form  the  ball  and 
socket  joint.  In  this  instrument  they  consist  of  two  bars  joined  in  their 
centers  and  swinging  on  a  pivot;  one  end  of  each  forms  the  socket  for 
clasping  the  reflector  knob,  while  the  other  is  opened  and  closed  by  means 
of  a  thumb-screw.  The  metallic  plate  is  longer  than  in  the  ordinary  pat- 
tern, and  the  band  attached  to  the  ends  of  the  plate  instead  of  passing 
between  it  and  the  pad. 


Figure  1465.    Fox's  Head-band. 


Figure  1466. 


USE 

Sardy's  Head-band. 


Fox's  Head-band,  as  portrayed  in  figure  1465,  consists  of  a  hinged  band 
encircling  the  head  from  front  to  back,  the  posterior  portion  terminating 
in  a  cross-bar  that  serves  to  furnish  a  comfortable  support.  The  anterior 
portion  consists  of  a  padded  plate  with  nasal  rest,  identical  in  construction 


ILLUMINATING  APPARATUS.  627 

with  the  pattern  of  Schroetter  previously  referred  to.  The  adjustment  of 
hinges  is  such  that  the  apparatus  serves  as  a  wrapper  or  protector  for  the 
reflector,  not  only  preventing  the  glass  from  being  broken,  but  rendering 
the  whole  portable.  A  solid  metallic  band  of  similar  form  may  also  be 
obtained.  It  is  provided  with  a  cross-piece  at  the  top,  so  that  it  rests  firmly 
on  the  head.  As  it  is  not  portable  it  is  suitable  only  for  office  use. 

Sardy's  Head-band,  as  illustrated  in  figure  1466,  consists  of  two  hem- 
ispherical discs  united  at  their  points  in  such  a  manner  that  they  rest 
together  as  one,  thus  forming  a  protector  for  the  mirror  when  not  in  use,  or 
swung  apart  until  both  rest  in  the  same  plane,  in  which  position  they  form, 
in  connection  with  the  tapes,  a  well-shaped  band  for  encircling  the  head. 
The  bar  uniting  the  halves  is  elongated  into  a  shank  that  terminates  in  a 
ball  similar  to  the  one  on  the  mirror  back.  A  short  double  socket  bar; 
that  is,  one  made  to  clasp  the  ball  at  each  end,  unites  the  reflector  and 
band. 

Reflector  Brackets. 

Plain  or  adjustable  brackets  are  preferred  by  a  few  operators,  who  argue 
that  they  furnish  a  steady  stream  of  light,  free  from  waverings.  They  are 
objected  to,  however,  by  many,  because  it  is  claimed  that  it  is  much  more 
difficult  to  keep  a  patient  in  the  proper  focus  of  the  mirror,  as  each  move- 
ment of  the  patient  requires  a  change  in  the  position  of  the  light.  Usually 
such  brackets  are  found  only  in  combination  with  some  form  of  condenser, 
examples  of  which  are  shown  in  connection  with  figures  1458  and  1459. 


Figure  1467.     Boekel's  Bracket  for  Reflector. 

Boekel's  Bracket,  as  shown  in  figure  1467,  is  one  of  the  best  forms  of 
fixed  brackets.  It  is  illustrated  in  connection  with  a  condenser,  shown  by 
figure  1456.  Other  patterns  have  been  constructed,  either  straight  or 
jointed,  one  of  the  latter  variety  being  manufactured  in  connection  with 
the  Tobold  condenser,  shown  by  figure  1459. 

Throat  Mirrors. 

Intra-cavity  mirrors  are  usually  known  as  throat  mirrors.  As  shown 
by  figure  1468,  they  are  small  delicate  glass  mirrors  attached  to  long  slender 
shanks  and  handles.  They  are  used  in  the  throat  to  illuminate  parts  that 
are  beyond  the  field  of  direct  vision.  The  combination  of  a  throat  mirror 
with  a  suitable  reflector,  when  used  for  examination  of  the  larynx,  is  usually 
called  a  laryngoscope.  If  the  mirror  be  turned  on  the  handle  axis  and  used 
to  inspect  the  naso-pharynx,  the  combination,  according  to  well-established 
authorities,  immediately  becomes  a  rhinoscope.  Why  the  act  of  turning 
the  mirror  up  or  down  should  change  the  name  of  the  appliance  in  use 
may  not  be  clear  to  the  dealer,  or  even  to  the  surgeon,  yet  the  fact  is 
indisputable. 

Throat  mirrors  are  usually  circular,  though  various  forms,  such  as  oval, 
square,  oblong,  etc.,  may  be  procured.  The  shanks  or  stems  are  of  wire 
attached  to  delicate  handles.  The  latter  may  be  fixed  or  removable. 


628  SURGERY    OF    THE    MOUTH    AND    THROAT. 

When  of  the  latter  pattern,  they  are  supplied  with  a  set  screw,  so  that 
.various  sizes  of  mirrors  may  be  used  with  a  single  handle.  The  back  and 
rim,  or  mounting  of  the  mirror  are  usually  constructed  as  light  as  is  con- 
sistent with  the  necessary  strength.  This  metallic  frame  should  fit  closely 
to  the  mirror  glass,  covering  as  little  as  possible  of  the  front  or  reflecting 
surface  of  the  same.  The  mirror  plane  ordinarily  forms  an  angle  with  the 


Figure  1468.    Thi  oat  Mirrors. 

handle  of  120°  to  125°.  By  raising  or  lowering  the  handle,  thereby 
increasing  or  decreasing  the  angle  of  obliquity  with  reference  to  the 
reflected  beam  of  light,  the  desired  parts  may  usually  be  illuminated.  In 
extreme  cases  the  handles  will  be  found  sufficiently  flexible  to  be  curved 
to  any  desired  angle.  This  bending  should  be  done  with  a  strong  pair  of 
forceps,  otherwise  the  mirror  mounting  may  be  broken  at  its  point  of 
attachment  with  the  shank. 

In  the  construction  of  these  mirrors,  reliable  makers  have  vied  with 
each  other  in  attempts  at  producing  the  lightest,  finest  and  most  brilliant 
instrument  possible.  Others  finding  that,  owing  to  loss  by  breakage  and 
the  great  care  necessary  in  handling,  it  costs  less  to  cut  and  mount  glass 
of  ordinary  thickness,  than  extra  thin  sheets,  have  placed  inferior  mirrors 
of  unnecessary  thickness  on  the  market. 

While  throat  mirrors  can  be  successfully  manufactured  with  a  thickness 
of  about  i  y?  millimeters,  including  the  metal  back,  those  2  y2  millimeters 
in  thickness  are  not  uncommon. 

The  glass  employed  in  the  construction  of  these  mirrors  should  be  what 
is  known  as  "crystal,"  of  a  quality  white  and  clear.  The  amount  of  dis- 
coloration in  a  glass  may  be  determined  in  the  same  manner  that  plate- 
glass  and  mirrors  are  tested  by  dealers.  This  is  accomplished  by  holding 
a  white  card  at  an  acute  angle  with  the  mirror,  the  mirror  being  turned 
toward  the  light  and  the  card  touching  the  lower  edge  of  the  mirror.  By 
noticing  the  color  of  the  card  as  reflected  on  the  mirror,  the  difference 
between  the  reflection  and  the  natural  color  of  the  card  shows  the  amount 
of  discoloration  produced  by  the  rays  of  light  passing  through  the  glass. 
In  a  good  quality  of  glass  the  reflection  should  be  equally,  or  quite  as  white 
as  the  card  itself.  Diffused  daylight  should  be  used  for  this  test. 

Mirrors  for  this  purpose  are  made  from  sheet-glass  with  amalgam  or 
silver-leaf  reflecting  surfaces.  The  latter  is  by  far  the  more  durable  as  it 
better  withstands  the  action  of  both  heat  and  moisture. 

It  is  necessary  to  warm  a  throat  mirror  before  its  introduction  in  order 
to  prevent  condensation  of  moisture  on  the  mirror  surface,  as  this  prevents 
perfect  reflection.  Care  must  be  taken  in  the  warming  process  to  prevent 
overheating,  particularly  when  using  amalgam-coated  mirrors.  Usually 
exposure  for  two  or  three  seconds  over  a  lamp  will  be  sufficient,  the  degree 
of  heat  necessary  being  determined  by  pressure  of  the  instrument  on  the 
back  of  the  hand.  In  each  case,  the  mirror  selected  by  the  surgeon  should 


THROAT    MIRRORS. 


629 


be  as  large  as  the  cavity  of  the  fauces  will  admit,  because  the  larger  the 
mirror,  the  more  intense  the  illumination.  The  sizes  adopted  by  dealers- 
vary  with  the  country  in  which  the  mirrors  are  manufactured  and  with  the 
ideas  of  the  maker. 

As  the  difference  between  each  size  is  usually  fa  of  an  inch,  we  suggest 
that  in  the  future  throat  mirrors  be  marked  in  such  a  manner  that  the  number 
of  the  glass  shall  correspond  to  the  number  of  eighths  of  inches  in  the  diam- 
eter of  the  circle.  Thus  a  No.  3  would  be  fa  of  an  inch  in  diameter,  a  No.  4,  -f- 
of  an  inch,  etc.  Usually  the  sizes  range  from  fa  of  an  inch  to  ifa  inches  in 
diameter,  though  mirrors  i^  inches  in  diameter  are  occasionally  in  de- 
mand. Their  extreme  length  is  about  8  inches.  Ingals  recommends  a  set 
of  four  mirrors,  three  round  ones,  fa,  "/%  and  f  of  an  inch  in  diameter,  and 
one  oval  one  ^  °f  an  mcn  in  diameter,  the  latter  for  enlarged  tonsils. 


Figure  1469.     Electric  Throat  Mirror. 

The  Electric  Throat  Mirror,  exhibited  in  figure  1469,  combines  an 
ordinary  laryngoscopic  mirror  with  a  small  electric  light,  the  latter  placed 
directly  in  front  of  the  mirror.  It  is  supplied  with  a  suitable  handle,  pro- 
vided with  a  spring  cut-off,  by  which  the  current  may  be  instantly  turned 
on  or  off.  The  electric  lamp  is  attached  with  a  screw,  so  that  it  may  be 
replaced  at  any  time  when  damaged. 


Figure  1470.    Pocket  Laryngoscopic  Set. 

The  Laryngoscopic  Set,  as  shown  in  figure  1470,  is  intended  particu- 
larly for  pocket  use.  It  embraces  the  instruments  necessary  for  making 
an  examination  of  the  throat  or  naso-pharynx.  It  consists  of :  Bosworth's 
tongue  depressor,  figure  1441;  3^-inch  reflector,  and  Schroetter's  head- 
band, figure  1463;  6  throat  mirrors,  assorted  sizes,  with  universal  handle, 
figure  1468;  silver  probe,  and  3  applicators;  all  contained  in  a  leather  case 
with  metal  frame. 


630 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


Epiglottis  Retractor. 


Some  form  of  retractor  may  be  required  in  certain  cases  to  raise  or 
elevate  the  epiglottis,  when,  from  any  cause,  it  obstructs  the  field  of  vision. 
Among  the  instruments  devised  for  this  purpose  are  staffs  or  probes,  and 
forceps. 

Epiglottis  Staff. 

This  is  a  probe-like  instrument,  of  metal  or  other  firm  material,  bent  at 
its  distal  end  in  such  a  manner  that  it  may  be  passed  behind  the  lip  of 
the  epiglottis  and  draw  it  forward.  In  the  absence  of  an  instrument 
especially  constructed  for  this  purpose  the  operator  may  employ  a  silver 
probe,  bending  it  to  the  desired  form. 


Figure  1471.    Voltolinis'  Staff. 

Voltolinis'  Staff  consists  of  a  slender  rod,  usually  of  metal,  though  occa- 
sionally of  whalebone,  and  curved  at  its  distal  end,  as  illustrated  in  figure 
1471. 

Forceps  for  forcibly  retracting  the  epiglottis,  should  have  mouse  teeth, 
and  be  of  such  a  curve  that  while  engaged,  the  instrument  may  not  obstruct 
the  field  of  vision. 


B.TIEMANN  &  CO. 
Figure  1472.     Bruns'  Epiglottis  Forceps. 

Bruns'  Epiglottis  Forceps,  as  shown  by  figure  1472,  consists  of  a  delicate 
double  tenaculum,  operated  by  a  self-acting  spring.  One  blade  of  the 
instrument  is  solid  or  fixed,  the  other  jointed  near  the  shaft  by  means  of  a 
post  and  slot  and  so  adjusted  that  pressure  upon  the  handles  separates  the 
tips  or  tenacula.  By  releasing  the  pressure,  the  jaws  are  closed  by  the 
action  of  the  spring.  This  instrument  may  be  utilized  for  many  other 
operations  in  the  pharynx  and  naso-pharynx. 


RELIEF  OF  INFLAMMATION. 

Inflammation  of  the  throat,  whether  acute  or  chronic,  general  or  only 
involving  a  single  organ,  may  be  treated  by  local  applications  or  the 
galvano-cautery.  This  may  require  one  or  more  of  the  following- 
appliances  : 

Sprays,  powder  blowers,  cotton  holders,  swabs,  etc.,  for  applying 
medicaments;  applicators  for  caustics,  and  the  galvano-cautery. 

Sprays. 

Sprays,  for  therapeutic  use,  consist  of  liquids  that  by  mechanical  or 
other  agency  have  been  converted  into  spray,  vapors,  steam,  etc.  Like 
ordinary  solutions,  they  are  employed  for  purposes  of  direct  medication, 


RELIEF    OF    INFLAMMATION. 


631 


disinfection,  washing,  etc.  They  are  produced  either  by  compressed  air 
or  steam. 

The  value  of  compressed  air,  either  when  used  for  conveying  medica- 
ments into  the  various  cavities  of  the  body,  or  as  a  direct  mechanical  agent, 
is,  we  believe,  well  known  and  appreciated.  As  a  means  of  diagnosis  in 
certain  ear  affections,  it  is  almost  indispensable. 

Experience  has  demonstrated  that  it  forms  an  efficacious  method  of 
applying  either  solutions  or  powders  to  the  sinuses  of  the  nares,  the 
cavities  of  the  larynx  and  pharynx,  and  even  to  the  tubes  and  air  cells  of 
the  lungs.  Formerly  this  was  accomplished  by  the  use  of  rubber  bulbs, 
but  it  has  since  been  well  established  that  better  results  may  be  obtained 
by  using  air,  not  only  in  considerable  volume,  but  under  a  pressure  of  from 
25  to  50  pounds  to  the  square  inch. 

Usually,  the  air  is  condensed  by  some  form  of  pump  and  stored  in  cylin- 
ders until  wanted  for  use,  or  it  is  compressed  as  wanted  by  small  pumps 
or  the  forced  collapse  of  rubber  bulbs  or  bags.  The  cylinder  system  not 
only  furnishes  air  in  sufficient  force  and  volume,  but  if  arranged  with 
suitable  connections  it  may  be  operated  with  one  hand,  leaving  the  other 
free  to  hold  a  speculum,  tongue  depressor  or  other  instrument. 

Air  Pumps. 

In  selecting  a  pump,  the  physician  should  not  lose  sight  of  certain  well- 
known  mechanical  principles  that  must  be  employed  in  air  condensation. 
The  amount  of  pressure  obtained  in  a  given  time  must  be  in  exact  propor- 
tion to  the  force  employed.  If  a  high  pressure  is  desired,  it  must  be  secured 


Figure  1473.     Plain  Hand  or  T-Pump. 


Figure  1474.     Lever  Oscillating  Pump. 


either  with  a  small  cylinder  operated  for  a  considerable  length  of  time  by 
a  moderate  force,  or  a  large  cylinder  with  which  the  reservoir  may  be 
quickly  filled,  provided  a  powerful  force  is  exerted. 


632 


SURGERY    OF    THE    MOUTH    AND    THROAT. 


Many  forms  of  pumps  are  constructed  with  levers,  in  order  to  secure  a 
greater  amount  of  compressing-  power.  In  the  employment  of  the  lever 
principle,  however,  the  operator  should  remember  that  in  proportion  as 
the  power  is  increased,  the  length  of  stroke  is  decreased,  so  that  what  is 
gained  in  power  is  lost  in  time,  and  that  if  the  surgeon  attempts  to  com- 
pensate for  the  loss  of  time  by  increasing  the  size  of  the  cylinder,  he  will 
only  necessitate  a  corresponding  increase  in  power.  Various  forces  are 
utilized  in  operating  pumps  for  air  compression.  Among  these  are  direct 
hand  pressure,  or  lever  force,  steam,  electricity  and  water.  The  use  of 
hand  pressure,  probably  the  most  common,  is  exhibited  not  only  in  the 
ordinary  hand  or  T-pump,  but  in  various  oscillating  and  lever  pumps. 

The 'Plain  Hand  or  T-Pump,  as  indicated  in  figure  1473,  is  the  most 
common  apparatus  employed  for  air  compression.  The  amount  of  pressure 
that  may  be  secured  in  a  cylinder  depends  on  the  force  exerted,  the  time  of 
operation  and  the  size  of  the  piston.  Those  in  common  use  have  a  piston 
about  2  inches  in  diameter,  with  a  15 -inch  stroke.  With  this,  a  pressure  of 
from  25  to  40  pounds  may  be  secured  with  a  fair  outlay  of  manual  labor. 
If  a  higher  pressure  is  desired,  a  pump  with  a  piston  i^  to  \y2  inches  in 
diameter  should  be  employed. 

The  Lever  Oscillating  Pump,  which  is  shown  in  figure  1474,  consists  of 
a  short  cylinder  attached  to  a  firm  base  by  means  of  a  hinge  or  joint,  the 
piston  rod  being  secured  to  a  swinging  lever.  When  the  latter  is  moved 


Figure  1475.    Double  Lever  Cylinder  Pump. 


Figure  1476.    Wheel  Oscillating  Pump. 


backward  or  forward,  the  pump,  swinging  upon  the  axis  of  its  hinged 
attachment,  accommodates  itself  to  the  changing  position  of  the  lever,  thus 
avoiding  a  loss  of  power  by  lateral  pressure  of  the  piston  shaft  either  upon 
the  cylinder  or  the  collar  through  which  the  shaft  passes. 


AIR   COMPRESSING     APPARATUS. 


G33 


Ordinarily,  this  form  of  pump  is  constructed  with  a  cylinder  2  y?  inches 
in  diameter  and  with  a  6-inch  stroke.  The  lever  or  handle  bar  is  about 
42  inches  in  length,  the  pump'  being-  attached  6  inches  from  the  terminal 
hinge  of  the  bar.  The  only  objection  to  this  form  of  pump  is  the  long 
sweep  necessary  in  its  operation,  which  is  tiring  if  continued  for  a  consid- 
erable length  of  time. 

The  Double  Cylinder  Lever  Pump,  the  form  of  which  is  made  clear  in 
figure  1475,  is  one  °f  the  most  satisfactory  of  its  class.  As  it  is  constructed 
with  two  cylinders,  compression  of  air  is  effected  with  both  forward  and 
backward  movements  of  the  lever,  so  there  is  no  loss  of  time  in  its  oper- 
ation. The  cylinders  are  each  3  inches  in  diameter  with  a  4-inch  stroke. 
They  are  operated  by  a  lever  bar,  about  38  inches  in  length,  while  the 
distance  from  the  piston  to  the  fulcrum  is  about  4  inches.  With  this,  a 
pressure  of  50  pounds  in  an  ordinary  8  by  28-inch  cylinder  may  be  secured 
in  from  two  to  five  minutes. 

The  Wheel  Oscillating  Pump,  portrayed  by  figure    1476,  consists  of  an 


Figure  1477.    The  Eureka  Compound  Hydraulic  Pump. 


oscillating  pump,  the  cylinder  and  piston  together  with  other  adjustments 
being  similar  to  that  illustrated  in  figure  1474,  excepting  that  in  this  appa- 
ratus these  parts  are  hinged  in  a  nearly  vertical  position.  The  piston  is 


Figure  1478.    The  Victor  Air  Compressor. 

operated  by  a  crank   movement,  which  is  imparted  by  a  large  balance 
wheel  with  a  suitable  handle. 

This  pattern  was  popular  for  some  years,  but  because  its  operation 
becomes  tiresome,  particularly  when  a  pressure  of  more  than  30  pounds  is 


634 


SURGERY    OF    THE    MOUTH    AND    THROAT. 


desired,  the  apparatus  is  now  little  employed,  excepting  when  connected 
with  steam  or  electric  power.  As  ordinarily  used,  the  pumps  are  con- 
structed with  a  2-inch  cylinder  and  a  1 2-inch  stroke. 

The  Eureka  Compound  Hydraulic  Pump,  as  illustrated  in  figure  1477, 
consists  of  a  double  cylinder,  so  constructed  that  an  air  pressure  twice  that 
of  the  water  pressure  may  be  obtained.  The  apparatus  is  under  perfect 
control  by  the  operator,  and  may  be  located  in  any  place  where  water  con- 
nections can  be  made. 

The  Victor  Air  Compressor  exhibited  in  figure  1478,  is  a  double  action 
pump,  operated  by  a  small  motor.  The  latter  can  be  operated  by  any 
continuous  current  of  from  100  to  500  volts  pressure.  With  this  apparatus, 
any  pressure  up  to  60  pounds  may  be  easily  maintained,  for  when  the 
pressure  reaches  a  maximum  point  the  motor  can  be  placed  in  operation 
by  a  switch  that  may  be  conveniently  located. 

Air  Receivers. 

These  may  be  procured  of  almost  any  form  and  size.  Usually,  they  are 
made  either  from  copper  or  steel.  Ordinary  sheet  iron  may  be  used  where  a 
pressure  of  not  to  exceed  15  pounds  to  the  square  inch  is  required.  Copper 
furnishes  the  most  desirable  material  for  reservoirs,  because  it  may  be  pol- 
ished and  nickel-plated,  and  thus  be  an  attractive  piece  of  office  furniture. 
Steel  should  be  selected  where  large  cylinders  are  necessary,  and  like  the 


Figure  1479.    Copper  Receiver.        Figure  1480.    Copper  Receiver. 


Figure  1481.    Steel  Receiver. 


hydraulic  pump  previously  referred  to,  they  may  be  located  either  in  the 
room  adjoining  the  office  or  upon  some  other  floor. 

It  is  advisable  in  selecting  a  receiver  that  one  of  good  size  be  chosen, 


AIR    COMPRESSING    APPARATUS.  635 

particularly  if  the  operator  expects  to  employ  it  in  daily  treatment  of  many 
patients. 

Ordinary  reservoirs  should  be  built  and  tested  to  withstand  a  pressure 
of  not  less  than  100  pounds  to  the  square  inch.  As  the  pressure  generally 
employed  does  not  exceed  50  to  60  pounds,  this  precaution  may  be  consid- 
ered safe. 

That  the  amount  of  air  pressure  may  be  known  at  all  times,  the  receiver 
should  be  supplied  with  a  reliable  pressure  gauge,  indicating  the  number 
of  pounds  pressure  exerted  upon  each  square  inch  of  surface.  The  more 
desirable  patterns  are  provided  with  two  air-cocks  of  .fine  and  accurate 
construction. 

The  cocks  and  valves  for  use  with  compressed  air  should  be  constructed 
with  great  accuracy,  because  air,  owing  to  its  elasticity  and  ready  diffusi- 
bility,  is  a  fluid  difficult  to  retain  in  compressed  form. 

The  Copper  Receiver,  shown  by  figure  1479,  is  9  inches  in  diameter  and 
12  inches  high,  or  12  inches  in  diameter  and  18  inches  high.  It  is  intended 
for  use  on  a  table  or  stand.  Many  operators  who  use  large  storage  tanks 
in  the  basement  or  in  an  adjoining  room,  place  one  of  the  smaller  receivers 
in  the  consultation  room,  connected  with  the  larger  one. 

The  Copper  Receiver,  described  by  figure  1480,  differs  from  the  one 
last  above  described  only  in  size.  Usually  it  is  7  inches  in  diameter 
and  28  inches  high.  A  special  pattern  10  inches  in  diameter  and  28  inches 
in  height  is  sometimes  made. 

The  Steel  Receiver,  delineated  in  figure  1481,  is  made  of  heavy  material 
of  boiler  construction,  with  extra  close  joints.  Generally  it  is  12  inches 
in  diameter  and  18,  30,  48  or  72  inches  in  height. 

Elastic  Tubing  for  Conducting  Compressed  Air. 

Tubing  to  connect  an  air  pump  with  a  receiver  must  be  manufactured 
with  walls  of  extra  strength,  as  otherwise  they  will  not  withstand  the 
necessary  pressure.  For  this  purpose  it  is  usually  manufactured  with  an 
inside  cloth  lining,  which  with  extra  heavy  walls  of  firm  material  answers 
the  required  purpose.  Tubing  employed  to  connect  the  receiver  with  cut- 
offs and  spray  tubes  may  in  addition  to  the  cloth  lining,  be  supplied  with  an 
external  covering  of  some  woven  fabric.  Silk  is  usually  used  for  this  pur- 
pose, fancy  colors  being  selected  for  braiding.  Such  a  tubing  should  be 
quite  elastic,  neat  in  appearance,  of  material  that  will  bear  constant  use 
and  at  the  same  time,  withstand  the  pressure  exerted  by  the  air  in  the  cyl- 
inder. 

Silk-covered  tubing  is  not  only  cloth  lined  but  covered  externally  with 
a  layer  of  braided  silk.  While  it  can  be  obtained  in  almost  any  size,  tubes 
of  j3^  of  an  inch  in  internal  diameter  are  generally  employed. 

Air  Cut-offs. 

The  accessories  required  for  use  with  an  air-compressing  outfit  consist 
of  cut-offs,  spray  tubes  and  possibly  some  form  of  powder  blower.  While 
a  current  of  compressed  air  from  a  receiver  may  be  brought  into  action  by 
opening  the  valve  connecting  the  exhaust  tube  with  the  cylinder,  such 
means  would  be  found  too  slow  and  too  difficult  to  manage  for  practical 
use.  As  a  convenience,  therefore,  and  to  enable  the  operator  to  secure  a 
prompt  discharge  from  a  spray  tube  and  to  instantly  discontinue  the  same, 
a  cut-off  valve  is  usually  employed  as  a  connector  between  the  discharge 
pipe  and  the  spray  tube.  The  better  patterns  are  so  arranged  that  the 


636 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


spray  tube  together  with   the   tubing   and  cut-off  may   be  held  with  one 
hand,  while  the  valve  is  opened  and  closed  with  a  thumb  movement. 


Figure  1482.    Plain  Automatic  Cut-off. 


Figure  14a3.    Davidson's  Cut-off. 


The  Plain  Automatic  Cut-off,  the  action  of  which  is  disclosed  by  figure 
1482,  is  arranged  to  fit  the  thimbles  usually  attached  to  the  ordinary  glass 
spray  tubes  designed  by  Sass.  As  a  majority  of  the  spray  tubes  on  the 
market  are  now  constructed  to  fit  this  style  of  cut-off,  it  might  be  called  a 
universal  pattern.  The  arrangement  of  the  air  openings  is  shown  by  the 
two  small  cross  sections,  exhibited  upon  either  side  of  the  base.  The  one 
on  the  left  is  shown  closed,  in  which  position  the  current  of  air  entering 
from  below  is  unable,  for  want  of  a  continuous  opening,  to  pass  through 
the  instrument.  On  the  right  side,  upon  pressing  the  thumb-piece,  the 
inner  circular  section  is  shown  revolved  ^  of  a  diameter,  thus  completing 
the  air  passage,  and  giving  to  the  air  an  uninterrupted  flow.  The  cut-off 
is  held  closed  by  a  spring  located  in  the  upper  portion  of  the  instrument, 
where  it  passes  underneath  the  thumb-piece. 

The  Davidson  Cut-off,  shown  by  figure  1483,  is  a  much  smaller  appliance 
than  the  one  last  described.  It  consists  of  a  small  piston  actuating  within 
a  cylinder.  The  piston  is  controlled  by  a  spiral  spring,  so  that,  when 
forced  outward  by  its  action,  the  side  opening  in  the  cylinder  through  which 
the  air  is  conducted  from  the  reservoir,  is  closed.  The  piston  is  supplied 
with  a  small  shaft  that  projects  through  the  top  of  the  apparatus.  By  com- 
pressing the  spiral  metallic  spring,  an  opening  is  secured  through  which  the 
air  flows  without  interruption. 

Spray  Tubes. 

Medicaments  in  liquid  form  may  be  converted  into  sprays,  either  coarse  or 
fine,  according  to  the  apparatus  employed.  Ordinarily,  those  appliances 
that  produce  a  coarse  spray  are  called  spray  tubes  and  atomizers,  while 
those  in  which  the  atoms  are  minutely  subdivided  are  called  vaporizers, 
nebulizers,  etc. 

In  constructing  spray  tubes,  atomizers,  etc.,  different  mechanical  prin- 
ciples are  employed.  Probably  the  oldest  of  these  methods  is  that  known 
as  the  Bergson.  This  consists  of  two  tubes,  each  with  tips  of  small  caliber, 
one  conveying  a  current  of  fluid  under  pressure  by  condensation,  the  other 
connecting  with  a  liquid,  and  so  adjusted  that  its  point  or  tip  lies  imme- 
diately in  front  of  and  at  right  angles  to  the  point  of  exit  of  the  fluid 
current. 


SPRAY  TUBES. 


637 


By  the  action  of  a  well-known  mechanical  principle,  the  fluid  current 
issuing  immediately  over,  or  by  the  tip  of  the  second  tube,  produces  in  the 
latter  a  vacuum,  causing  a  flow  through  the  tube  of  any  liquid  with  which 
the  tube  is  connected.  This  liquid  issuing  from  the  top  of  the  second  tube, 
when  brought  in  contact  with  a  current  of  fluid,  such  as  air,  steam,  etc. 
under  pressure  is  immediately  broken  up  into  fine  particles,  in  which  condi- 
tion it  is  driven  out  in  the  form  of  a  spray.  This  form  of  vacuum  pressure 
will  draw  liquids  even  some  distance  below  the  level  of  the  air  tube.  Some 
forms  of  spray  tubes  employ  a  small  cup  into  which  the  liquid  is  poured, 
the  cup  being  either  on  a  level  with  the  tip  of  the  tube  or  slightly  above  or 
below  it. 

Except  as  a  matter  of  convenience  in  certain  classes  of  cases,  such  varie- 
ties possess  no  real  advantage.  Another  form  of  spray  tube  consists  in 
attaching  a  double  current  tube  to  a  bottle  or  reservoir,  uniting  the  two 
with  an  air-tight  joint.  One  of  the  tubes  extends  to  the  bottom  of  the  fluid 
receptacle,  while  the  second  one  admits  compressed  air  to  the  bottle  and 
also  conveys  a  current  of  the  same  to  the  tip  of  the  instrument.  Air 
pressure  on  the  surface  of  the  liquid  forces  the  latter  to  pass  outward 
through  the  inner  tube,  where  at  the  tip  it  is  caught  by  the  current  of  air 
issuing  at  this  point  and  by  it  is  converted  into  a  spray. 

Spray  tubes  may  be  manufactured  from  various  materials,  glass,  hard 
rubber  and  metal  being  employed.  Glass  is  preferred  by  some  operators, 
not  only  because  the  flow  of  liquids  may  be  watched  and  any  obstructions 
noted,  but  because  of  the  readiness  with  which  this  material  may  be 
cleansed.  The  objection  to  glass,  however,  is  the  liability  to  breakage, 
great  care  in  using  and  cleansing  being  necessary,  as  otherwise  the 
delicate  points  and  slender  tubes  may  be  broken. 


Figure  1484.    Old  Style  Sass'  Spray  Tubes. 


Hard  rubber  is  perhaps  the  most  popular  of  all  materials,  because  it  not 
only  withstands  the  action  of  corrosives,  but  it  admits  of  thorough  cleans- 
ing and  is  at  the  same  time  so  strong  that  breakage  seldom  occurs.  Metal 
is  little  used  because  it  so  readily  corrodes  under  the  action  of  many  reme- 
dies employed  in  treating  throat  and  nasal  affections. 


638 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


The  direction  in  which  the  spray  is  projected  depends  on  the  angle  of 
the  tube  employed  at  the  point  of  exit  of  the  fluid  current.  They  may  be  so 
turned  as  to  point  in  any  desired  direction. 

Sass'  Spray  Tube  is  one  of  the  oldest  and  best  known  among  this  class 
of  appliances.  As  originally  constructed,  it  consisted  of  two  heavy  glass  tubes 
of  small  lumen,  one  about  two-fifths  longer  than  the  other.  The  shorter  one 
was  cemented  to  its  mate  throughout  nearly  its  entire  length.  The  tip  of 
the  shorter  was  nearly  straight,  while  that  of  the  longer  was  curved  at 
almost  a  right  angle,  its  extreme  point  being  immediately  opposite  the 
opening  in  the  tip  of  the  shorter.  To  the  proximal  end  of  the  former  a 


Figure  1485.    Single  Piece  Sass'  Spray  Tube. 

small  metal  thimble  was  attached,  by  means  of  which  it  could  be  connected 
with  a  suitable  cut-off.  The  proximal  projection  of  the  longer  one  was 
curved  downward  at  an  angle  of  90°.  The  fluid  to  be  atomized  was  con- 
tained in  a  test  tube,  closed  by  a  cork  having  in  its  center  an  opening  of 
sufficient  size  to  admit  the  angular  portion  of  the  lower  tube.  The  direc- 


Figure  1486.    Rumbold's  Spray  Tubes. 

tion  of  the  spray  was  regulated  by  the  shape  of  the  tips  of  the  two  tubes. 
These  tips  were  objectionable  because  it  was  difficult  to  cleanse  the  space 
between  the  tubes,  and  because  their  points  were  so  slender  that  they  were 
easily  broken. 


SPRAY    TUBES.  639 

After  years  of  experimental  work  Elroy,  of  Boston,  succeeded  in  drawing 
a  glass  cylinder  with  a  double  bore  and  bringing  the  two  openings  together 
so  as  to  form  a  spray  upon  the  Bergson  principle,  as  exhibited  in  the  old 
style  of  Sass  tube.  This  new  feature  is  shown  in  figure  1485. 

The  old  style  of  spray  tube  attached  to  a  slender  bottle  by  a  metallic 
screw-cap,  is  illustrated  in  figure  1484,  the  whole  forming  a  great 
improvement  over  the  original  apparatus.  A  perforated  cork  placed  in 
the  upper  portion  of  the  metal  cap  forms  a  water-tight  connection  with  the 
bottle,  while  a  metallic  thimble  on  the  proximal  end  of  the  spray  tube 
furnishes  a  connection  for  a  cut-off. 

Rumbold's  Spray  Tubes,  as  displayed  by  figure  1486,  differ  from  the 
pattern  of  Sass  in  that  the  long  tube  of  the  latter  is  shortened  and  blown 
into  a  bowl  or  reservoir  for  the  liquid  to  be  atomized.  As  this  bowl  is 
located  slightly  above  the  point  of  exit,  it  has  the  additional  though  slight 
advantage  of  the  force  of  gravity.  They  are  preferred  by  some  specialists 
because  the  amount  of  medicament  may  be  measured,  and  the  exact  quan- 
tity required  placed  in  the  bulb.  They  are  constructed  from  both  glass 
and  metal. 

The  latter  is  particularly  adapted  for  the  administration  of  liquid  petro- 
latum, either  alone  or  in  combination.  When  the  petrolatum  is  used,  the 
bulb  may  be  held  in  the  flame  of  a  spirit  lamp  until  its  contents  are  heated 
sufficiently  to  produce  a  ready  flow. 


Figure  1487.    Devilbiss'  Universal  Spray. 

Devilbiss'  Universal  Spray,  as  shown  in  figure  1487,  is  constructed  with 
a  tip  so  arranged  that  it  may  be  turned  and  will  remain  in  any  position.  It 
therefore  becomes  universal  in  its  application,  as  a  spray  may  be  thrown  in 
any  desired  direction.  The  tube  supplying  the  fluid  connects  with  the  bot- 
tom of  a  metallic  reservoir  sufficient  in  capacity  for  a  large  number  of  appli- 
cations. 

This  spray  is  well  adapted  for  use  with  oils,  fluid  extracts,  aqueous  solu- 
tions and  liquid  petrolatum.  By  holding  the  reservoir  in  the  flame  of  a 
spirit  lamp,  oils,  petrolatum  and  similar  products  may  be  heated  until  a 
proper  consistency  is  reached,  after  which  they  may  be  used  in  the  spray 
tube. 

Davidson's  Sprays,  as  illustrated  in  figure  1488,  are  practically  modifica- 
tions of  the  Sass  tube.  In  their  construction,  the  tube  connecting  with  the 
supply  of  liquid  passes  through  the  tube  conveying  the  current  of  air,  both  is- 
suing from  the  tip  at  about  the  same  point  The  liquid  is  contained  in  bot- 
tles of  test-tube  form,  connected  with  the  tubes  by  means  of  collars. 
Thimbles  are  provided  and  attached  to  the  collars,  by  which  the  apparatus 
may  be  adjusted  to  a  cut-off. 

The  tubes  and  collars  are  manufactured  entirely  from  hard  rubber. 
Usually,  they  are  made  in  sets  of  three,  one  throwing  a  straight,  the  others 


640 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


up  and  down  sprays.  As  they  may  be  operated  with  a  low  pressure,  it  is 
possible  to  use  them  with  a  rubber  bulb.  The  bottles  are  of  extra  size,  and 
when  purchased  in  sets  are  usually  arranged  in  a  small  wooden  rack. 


Figure  1483.     Davidson's  Sprays. 

Sass'  Spray  Apparatus,  as  portrayed  in  figure  1489,  is  one  of  the  most 
desirable  outfits  on  the  market.  It  consists  of  a  hand  or  T-pump  (figure 
1473),  a  copper  reservoir  7  by  28  inches(figure  1480),  an  automatic  cut-off  (fig- 
ure 1483)  and  a  set  of  three  spray  tubes  (figure  1488).  The  tubing  leading 


Figure  1489.    Sass'  Spray  Apparatus,  Showing  Complete  Outfit. 

from  the  pump  to  the  cylinder  is  usually  cloth  lined,  while  that  leading 
from  the  cylinder  to  the  cut-off  is  silk  covered.  This  outfit  is  particularly 
adapted  to  the  needs  of  the  general  practitioner.  Cylinders  of  larger  size 
and  other  forms  of  pumps  may  also  be  obtained.  Dealers  are  ordinarily 
prepared  to  furnish  any  combination  of  pump,  receiver,  spray  tubes,  etc., 
that  may  be  desired. 

Vaporizers,  Nebulizers,  Etc. 

These  differ  from  the  spray  tubes  in  that  the  spray  stream  is  projected 
against  the  inner  wall  of  a  closed  chamber,  the  result  being  a  more  com- 
plete subdivision  of  the  liquid  particles.  An  in-rushing  air  flow  produces 
an  out-going  current.  This  current  passing  from  the  vessel  becomes  heav- 
ily charged  with  the  mist  or  vapor  contained  in  the  chamber,  resulting  in  a 
stream  containing  such  fine  particles  of  the  medicament  employed  that  it 


NEBULIZERS. 


641 


resembles  a  mist  or  cloud.  These  instruments  are  frequently  used  as  in- 
halers and  are  particularly  employed  in  diseases  of  the  lungs  and  in  cases 
of  acute  and  chronic  rhinitis  complicated  with  middle-ear  affections. 


Figure  1400.    Nebulizer.  Figure  1491.    Nebulizer  with  Pynchon's  Laryngeal  Tube. 

The  Nebulizer,  outlined  in  figure  1490,  presents  one  of  the  most  simple 
forms  of  appliances  of  this  kind.  In  this  apparatus  a  fine  stream  of  the- 
medicated  fluid  is  thrown  by  atmospheric  pressure  against  the  sides  of  the 
containing  bottle  with  sufficient  force  to  break  the  jet  into  a  fine  vapor. 
This  nebula  is  forced  out  through  a  large  opening  in  the  cork  into  the  exit 


Figure  1492.    The  Globe  Nebulizer. 


Figure  1493.    The  Universal  Nebulizer. 


pipe,  from  which  it  escapes  in  cloud-like  form.     The  discharge  pipe  may  be 
of  any  form    or  shape  desired. 

The  Globe  Nebulizer,  as  shown  by  figure  1492,  embodies  the  same  gen- 
eral principles  as  those  exhibited  in  the  apparatus  last  described.     A  circu- 


41 


642 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


lar  bowl  surmounted  by  a  screw-cap  having  two  openings  forms  the  princi- 
pal part  of  the  apparatus.  A  dependent  tube  is  arranged  to  throw  a  spray 
against  the  sides  of  the  globe.  The  apparatus  is  arranged  to  be  used  either 
with  compressed  air  or  a  compressing  bulb. 

The  Multiple  Nebulizers,  outlined  in  figures  1493  and  1494,  illustrate 
two  of  the  forms  in  which  nebulizers  are  grouped  together  with  a  view  to 
using  them  singly  or  in  combination.  This  apparatus  enables  the  surgeon 
to  form  a  nebula  from  one  or  more  of  the  globes  and  to  apply  the  vapor  by 
means  of  nasal  or  other  pipes.  As  these  appliances  require  from  15  to 
20  pounds  pressure  to  the  square  inch,  they  can  not  be  used  with  air- 
compressing  bulbs. 


Figure  1494.    Eureka  Nebulizer. 


Figure  1495.    Thomas'  Nebulizer. 


The  Thomas'  Nebulizer,  as  displayed  in  figure  1495,  consists  of  a  heavy 
glass  bottle  about  10  inches  in  height  and  4  in  diameter,  provided  with  a 
screw-cap  and  tested  to  withstand  a  pressure  of  50  pounds  to  the  square 
inch.  The  screw-cap  is  provided  with  two  openings,  through  which  tubes 
find  an  entrance  into  the  bottle.  One  of  these,  the  longer,  is  attached  to 
an  air-compressing  apparatus  extending  to  the  bottom  of  the  bottle.  This 
is  attached  to  a  spray  tube  after  the  plan  of  Bergson  previously  described. 
The  spray  issuing  from  the  tube  point  is  forced  by  strong  air  pressure 
against  the  sides  of  the  bottle,  where  it  is  converted  into  a  fine  nebula. 
The  shorter  pipe,  which  is  flush  with  the  under  side  of  the  cork  or  stopper, 
connects  with  the  dispensing  tube.  The  latter  may  be  supplied  with  any 
form  of  tip  desired.  This  apparatus,  when  properly  constructed,  forms  an 
efficient  means,  not  only  for  ordinary  medicinal  treatment,  but  for  inhala- 
tion purposes. 

The  Double  Bracket,  with  Lamp  and  Vaporizer,  illustrated  in  figure 
1496,  is  arranged  to  be  placed  upon  a  table  or  stand  and  is  designed  for  use 
with  an  oil  lamp.  Two  brackets,  one  upon  either  side,  are  jointed  so  as 
to  swing  in  any  direction.  A  perpendicular  adjustment  is  also  provided,  by 
means  of  which  the  bracket  terminals  may  be  raised  to  any  desired  height, 
where  they  may  be  held  in  place  by  milled  nuts  and  stops.  The  vaporizer 
may  be  of  any  desired  pattern,  and  may  be  attached  to  any  suitable  air 


ATOMIZERS. 


643 


receiver.  The  base  of  the  stand  is  arranged  so  that  it  may  be  firmly  at- 
tached to  the  surface  upon  which  it  rests  to  avoid  accidents.  A  gas  arrange- 
ment may  be  substituted  for  the  oil  lamp. 


Figure  14%.     Double  Table  Bracket  with  Lamp  and  Vaporizer. 

Atomizers. 

Spray  tubes  operated  by  the  compression  of  a  rubber  bulb  are  termed 
atomizers.  They  are  generally  constructed  with  a  hard  rubber  double-cur- 
rent tube  by  placing  a  tube  of  smaller  caliber  within  a  larger  one.  When 
so  designed  the  smaller  tube  extends  to  the  bottom  of  the  bottle  or  reservoir, 
and  is  the  one  employed  to  conduct  the  fluid  to  the  tip,  where,  meeting  with 
the  air  current,  it  issues  from  a  small  opening  mixed  with  air  in  the  form 
of  a  spray.  Such  atomizers  may  be  constructed  with  various  shaped  tips, 
curved  or  straight,  and  with  one  or  more  openings. 

The  pattern  of  atomizer  employed  must  depend  on  the  nature  of  the 
fluid  to  be  sprayed  and  the  quantity  to  be  applied.  It  is  annoying  to 
patients  to  introduce  or  remove  from  the  nose  or  throat  an  atomizer  while 
spray  is  issuing  from  its  tip.  It  is  therefore  necessary  that  the  flow  com- 
mence and  end  while  the  atomizer  tip  is  in  situ.  As  a  rule,  the  starting  and 
discontinuing  of  a  spray  stream  will  be  found  under  better  control  in  an 
atomizer  where  short  tubes  and  small  reservoirs  are  employed.  Atomizers 
with  small  bottles  and  short  and  fine  tubes  should  therefore  be  employed 
when  only  small  quantities  of  liquid  are  to  be  applied. 

Atomizers  of  this  class  may  be  provided  with  single  or  double  bulbs. 
The  object  of  the  second  bulb  is  to  supply  an  elastic  reservoir  that  will 
maintain  a  spray-producing  pressure  during  the  filling  of  the  first  or  forcing 
bulb.  Usually  they  are  so  arranged  that  the  second  bulb  is  dilated  or  ex- 
panded to  its  full  capacity  before  the  pressure  is  sufficient  to  produce  spray. 
It  is  evident  that  the  bulb  acting  as  a  reservoir  must  either  be  constructed 
of  firm  material  or  that  the  manufacturer  must  provide  means  for  protect- 
ing it  from  bursting. 

American  manufacturers,  as  a  rule,  construct  bulbs  from  white  rubber 
with  walls  sufficiently  thick  to  withstand  the  necessary  pressure.  In 
Europe  pure  gum  rubber  is  used  for  this  purpose,  the  bulb  employed  for  air 
storage  being  placed  within  a  silk  spherical  net  with  coarse  mesh  and 
woven  in  fancy  colors. 

The  Ordinary  Atomizer,  delineated  in  figure  1498,  shows  one  of  the  many 
forms  of  this  class  of  instruments. 


644 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


It  consists  of  a  bottle,  collar  and  hard  rubber  tube,  the  latter  provided 
with  three  tips,  straight,  curved  and  acorn-shaped  for  use  in  the  anterior 
nares.  The  bulbs  are  of  firm  material  and  supplied  with  two  valves,  one 


Figure  1497.    Oil  Atomizer. 


Figure  1498.    Ordinary  Atomizer. 


admitting   air  to  the  bulb,  the  second  retaining  the   air   pressure  in  the 
apparatus  while  the  bulb  is  being  refilled  with  air. 

The  Oil  Atomizer,  represented  in  figure  1497,  is  constructed  to  throw  a 
spray  composed  of  fine  particles  of  medicament.     It  nearly  approaches  some 


FigAire  1499.    Author's  Atomizer. 

of  the  forms  of  vaporizers  described  by  figures  1490  to  1495.  In  the  con- 
struction of  this  instrument,  a  cylinder  or  perforated  dome  extends  upward 
or  beyond  the  spray  tube.  This  dome  is  so  shaped  that  many  of  the  sprayed 
particles  are  forced  against  its  inner  walls,  the  result  being  a  more  com- 
plete subdivision  of  the  liquid  particles.  The  instrument  is  compact  in 
form  and  may  easily  be  held  and  operated  with  one  hand.  It  is  particularly 
adapted  for  use  with  oils  and  mucilaginous  liquids.  It  is  employed  prin- 


ATOMIZERS. 


645 


cipally  in  throwing  injections  into  the  anterior  nares,  and  in  treating  dis- 
eases of  the  pharynx  and  fauces. 

The  Author's  Atomizer,  illustrated  in  figure  1499,  consists  of  a  heavy 
flint  bottle  with  broad  base,  to  the  neck  of  which  a  hard  rubber  collar  is 
securely  attached.  To  the  upper  face  of  the  latter  a  double-atomizing  tube 
with  T-shaped  connection  and  compression  bulb  is  attached  by  a  screw 
joint.  The  atomizing  tips  are  five  in  number :  Straight,  curved  at  a  right 
angle,  recurved,  anterior  nasal  and  a  post-nasal  jet  in  fan  shape.  As  the  tips 
are  universal,  the  atomizer  may  be  obtained  with  one  or  more  tips,  as  de- 
sired. 


Figure  1500.    Hawley's  Atomizer. 


Hawley's  Atomizer,  as  shown  in  figure  1500,  differs  from  the  pattern 
previously  described,  in  that  the  delivery  tube  is  single,  the  spray  being  de- 
livered in  the  form  of  five  jets,  projected  from  minute  openings  near  the  dis- 
tal end  of  the  instrument.  As  the  delivery  tube  of  this  apparatus  is  small 
and  flexible,  the  instrument  is  admirably  adapted  for  passage  through  the 
nose  into  the  posterior  nares.  It  is  constructed  for  use  either  with  a  bulb  or 
compressed  air  apparatus. 


Figure  1501.      Camenthol  Atomizer. 

The  Camenthol  Atomizer,  outlined  by  figure  1501,  combines  some  of  the 
mechanical  features  of  several  previously  described  appliances.  It  consists 
of  the  tips  of  a  Sass  spray  tube,  surrounded  by  a  long  egg-shaped  globe. 
The  longer  or  air  tube  of  the  Sass  spray  is  blown  into  and  forms  a  part 
of  the  base  of  the  globe,  the  rear  opening  of  which  is  entirely  closed 
by  the  passage  through  it  of  the  tube  referred  to.  This  tube  is  con- 


646 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


nected  by  a  short  shoulder,  with  an  ordinary  forcing  tube.  If  liquid  be 
poured  into  the  globe,  as  shown  by  the  darkened  line  in  the  illustration 
referred  to,  it  will  be  caught  and  drawn  into  the  air  current  by  the 
lower  of  the  two  spray  tips.  The  elongated  globe  assists  in  minutely  sub- 
dividing the  atomized  particles,  thus  furnishing  an  instrument  with  which 
a  fine  spray  may  be  produced. 

•  Steam  Sprays. 

Steam  sprays  are  those  in  which  steam  is  employed  as  a  force  or  medium 
for  conveying  medicament  to  affected  parts.  While  steam  for  this  purpose 
may  be  generated  in  any  manner  desired,  it  is  more  convenient  to  employ 
small  boilers  arranged  so  they  may  be  heated  by  an  ordinary  spirit  lamp. 
These  boilers  are  usually  mounted  in  frames  or  supports  and  arranged 
with  safety  valves,  that  accidental  explosions  may  not  result. 

The  steam  in  this  class  of  apparatus  is  passed  through  the  short  arm  of 
the  spray  tube,  operating  exactly  in  the  same  manner  as  that  described  in 
connection  with  the  Sass  tube,  figure  1484.  The  medicament,  in  liquid 
form,  may  be  placed  in  any  desired  receptacle,  whence  it  may  be  turned 
into  and  form  a  part  of  the  steam  current  by  vacuum  pressure.  Steam  atom- 
izers are  principally  employed  in  croupous  affections  and  diseases  of  the 
lungs. 


Figure  1502.     American  Steam  Atomizer. 

The  American  Steam  Atomizer,  as  sketched  in  figure  1502,  consists  of 
a  small  spherical  brass  boiler  about  3  inches  in  diameter,  arranged  to  rest 
in  a  cylindrical  frame  directly  in  the  flame  of  a  small  spirit  lamp.  The  lat- 
ter is  of  sufficient  capacity  to  generate  as  much  steam  as  is  necessary  for 
spraying  purposes.  Two  openings  are  provided  in  the  boiler  near  its  top, 
one  upon  each  side.  One  is  to  enable  the  operator  to  fill  the  boiler  with 
water.  This  is  closed  with  a  screw-cap,  in  the  center  of  which  a  small 
safety  valve  is  placed,  so  arranged  as  to  open  whenever  the  pressure  be- 
comes too  great.  The  second  opening  is  at  the  distal  end  of  a  small  cylinder 
projecting  horizontally  from  the  boiler.  It  is  arranged  to  receive  a  small 
spray  tube  constructed  on  the  Bergson  plan. 

The  medicament  to  be  used  is  contained  in  a  small  glass  vessel,  which 
rests  securely  on  a  bracket  attached  to  the  side  of  the  boiler  support.  The 
lower  arm  of  the  spray  tube  connects  with  this  cup.  That  the  spray  may 
be  concentrated  for  inhalation,  a  funnel-shaped  mouth-piece  is  provided,  into 


INHALERS POWDER    BLOWERS. 


647 


which  the  spray  is  directed.  This  rests  upon  a  metallic  standard  attached 
to  a  projection  of  the  base.  As  a  portion  of  the  spray  will  condense  upon 
the  sides  of  the  glass  funnel,  more  or  less  dripping-  of  water  must  follow. 
A  drip-cup  is  provided  by  means  of  which  this  is  caught,  thus  preventing  it 
from  soiling  the  table,  clothing;  etc. 

Inhalers. 

These,  as  generally  found  on  the  market,  consist  of  devices,  by  means 
of  which  steam  mixed  with  medicaments,  the  vapors  arising  from  chem- 
ical action,  or  those  due  to  the  dissipation  of  ethereal  preparations,  may  be 
inhaled. 


Figure  1503.    Hunter's  Inhaler. 


Figure  1504.    Croup  Kettle. 


Hunter's  Inhaler,  as  represented  in  figure  1503,  consists  of  a  bottle  of 
broad  and  low  construction  provided  with  two  openings,  one  of  which  is 
used  for  the  injection  of  the  medicament,  and  the  other  for  the  attachment 
of  a  rubber  hose  and  inhaling  tube.  The  medicament  is  placed  within  the 
bottle,  which  is  kept  hot  by  immersion  in  a  basin  of  hot  water.  By  means 
of  a  mouth-piece  the  patient  may  inhale  the  steam  and  "vapors  generated 
in  the  bottle. 

The  Croup  Kettle,  pictured  in  figure  1504,  consists  of  a  small  boiler, 
heated  by  a  spirit  lamp,  the  whole  contained  within  a  metallic  frame  or 
cylinder.  The  boiler  is  supplied  with  a  funnel,  the  opening  through  which 
may  be  closed  with  an  ordinary  cork.  A  second  opening  in  the  boiler  top 
is  formed  by  the  insertion  of  a  tube,  the  latter  being  lengthened  as  desired 
by  extensions  like  stove  pipe.  Either  pure  water  or  any  desired  medica- 
ment may  be  placed  within  the  boiler  and  the  escaping  steam  inhaled. 

Powder  Blowers. 

These  consist  of  some  form  of  receptacle  for  powder,  so  arranged  that 
by  the  passage  of  a  current  of  air  over  the  surface  of  the  powder,  particles 
of  the  latter  will  be  caught  in  the  current  and  conveyed  through  a  tube  to 
the  affected  parts. 

One  class  consists  of  a  bottle  or  other  reservoir  provided  with  inlet  and 
outlet  tubes,  the  compressed  air  passing  into  the  receptacle  through  one 
and  out  through  the  other.  This  current  conveys  with  it  a  certain  quantity 
of  any  finely-powdered  drug  that  may  be  contained  within  the  vessel. 

In  the  second  variety  the  powder  is  introduced  directly  into  a  slender 


618 


SURGERY    OF    THE    MOUTH    AND     THROAT. 


tube,  air  being  forced  through  the  tube  either  by  a  compressed  air  appara- 
tus, by  blowing  with  the  mouth,  or  by  the  compression  of  a  rubber  bulb. 

A  small  oval  opening  is  provided  in  one  side  of  the  tube,  into  which  the 
powder  to  be  injected  may  be  introduced.  This  opening  is  covered  by  a 
sliding  collar,  forming  a  tight  joint.  After  the  instrument  is  charged,  it 
may  be  introduced  into  the  throat,  and  the  full  amount  of  powder  injected 
with  a  single  compression  of  the  bulb.  The  better  forms  of  these  instru- 
ments are  constructed  with  a  small  valve  at  the  distal  end,  so  arranged  as 
to  partially  close  the  center  of  the  opening,  causing  the  powder  to  spread 
in  the  form  of  a  fountain  spray.  This  is  to  prevent  the  depositing  of  the 
powder  in  a  limited  space.  It  also  serves  to  prevent  a  strong  return  cur- 
rent from  carrying  powder  into  the  bulb  when  the  latter  is  refilled. 


Figure  1504A.    Clay's  Powder  Blower. 


Clay's  Powder  Blower,  as  exhibited  in  figure  15 04 A,  is  of  the  pattern 
above  described.  It  commanded  an  extensive  sale  until  the  introduction 
of  the  scoop  pattern  illustrated  in  figure  1505. 


Figure  1505.    Scoop  Powder  Blower. 

The  Scoop  Powder  Blower,  as  shown  in  figure  1505,  consists  of  a  separable 
tube,  the  two  connected  by  means  of  a  slip-joint.     The  distal  half  of  the 


Figure  1506.     Author's  Powder  Blower. 


tube  is  constructed  in  scoop  form.     This  enables  the  operator  to  scrape  up 
or  remove  from  a  wide-mouthed  bottle  the  amount  of  powder  required  for 


POWDER  BLOWERS. 


649 


application.  The  scoop  portion  may  then  be  inserted  into  the  cylinder 
forming  the  proximal  end  of  the  tube,  and  a  tight  joint  effected.  The 
powder  is  deposited  by  the  compression  of  a  rubber  bulb,  as  previously 
described. 

The  Author's  Powder  Blower,  as  displayed  in  figure  1506,  consists  of  a 
stout,  heavy  bottle,  the  neck  of  which  is  fitted  with  a  hard  rubber  cap.  To 
this  a  double  upright  tube  is  attached,  as  in  ordinary  atomizers.  The  inner 
tube  extends  from  the  bottom  of  the  bottle  to  the  exit.  The  outer  is  in 
T-form,  and  connects  with  an  air-forcing  bulb  by  a  rubber  hose.  The 
tips  are  attached  by  slip  joints  and  are  four  in  number,  one  straight,  one 
slightly  curved,  one  full  curved  or  nearly  at  a  right  angle,  and  the  fourth 
recurved,  thus  permitting  the  expulsion  of  the  powder  stream  in  any 
desired  direction.  As  the  bottle  has  a  broad  base,  it  is  not  easily  over- 
turned. It  can  be  procured  either  as  shown  in  the  illustration  or  arranged 
for  attachment  to  anv  form  of  cut-off. 


Figure  1507.    Devilbiss'  Powder  Blower. 


Devilbiss'  Powder  Blower,  as  exhibited  in  figure  1507,  is  a  small,  flat 
metallic  or  glass  bottle,  with  slip-over  cap  and  stopper.  The  latter  is  pene- 
trated by  two  curved  tubes,  one,  the  shorter,  connected  by  a  hose  with  an 
ordinary  forcing  bulb.  The  longer  tube  extends  nearly  to  the  bottom  of 
the  bottle  and  projects  from  the  cap  in  a  line  parallel  with  the  bottom  of 
the  bottle.  It  is  constructed  to  diffuse  powder  perfectly,  and  is  provided 
with  three  tips,  one  straight,  one  curved  nearly  at  a  right  angle,  and  one 
recurved  for  use  in  the  posterior  nares.  Either  of  the  two  latter  may  be 
turned  so  as  to  throw  laterally,  to  right  or  left. 


Figure  1508.    German  Powder  Blower. 


Figure  1509.     Bishop's  Powder  Blower. 


The  German  Powder  Blower,  as  illustrated  in  figure  1508,  consists  of  a 
straight,  hard  rubber  cylindrical  tube,  about  6  inches  in  length,  attached  to 
a  mouth-piece  by  a  soft  rubber  hose.  The  hard  rubber  portion  is  provided 
with  a  side  opening  for  the  introduction  of  the  powder.  Instead  of  a 


650 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


sliding  collar,  or  scoop,  a  small,  hard  rubber  reservoir  is  provided, 
through  the  bottom  of  which  the  cylindrical  tube  passes.  The  lower  por- 
tion of  this  reservoir  is  thick  and  constructed  of  solid  rubber,  the  lateral 
opening,  through  which  the  powder  tube  passes,  being  separated  from  the 
lower  surface  of  the  reservoir  by  a  thin  bridge.  An  oval  opening  is  pro- 
vided in  the  bridge  of  the  same  size  as  the  one  in  the  tube.  When  the  two 
openings  are  continuous,  a  charge  of  powder  will  drop  into  the  cylindrical 
tube.  By  turning  the  latter  to  the  right  or  left,  the  connection  with  the 
reservoir  is  closed,  when  by  blowing  through  the  tube,  the  powder  may  be 
deposited  upon  any  point  desired.  This  instrument  is  particularly  adapted 
for  the  use  of  iodoform.  Instead  of  the  mouth  and  lungs  being  employed 
as  an  air  compressor,  we  recommend  the  attachment  of  a  rubber  bulb  as 
being  more  in  keeping  with  aseptic  requirements. 

Bishop's  Powder  Blower,  as  shown  by  figure  1509,  consists  of  a  small 
wide-mouthed  bottle,  provided  with  a  rubber  cork,  through  the  openings  of 
which  an  inlet  and  outlet  tube  connect  with  the  bottle.  The'apparatus  is 
completed  by  a  piece  of  soft  rubber  hose  and  a  compression  bulb.  Powder 
placed  within  the  bottle  may  be  forced  through  the  out-going  tube,  from 
which  it  issues  in  the  form  of  a  spray.  The  instrument  is  simple  in  con- 
struction and  is  sold  at  a  low  price. 


Figure  1510.      Ingals'  Powder  Blower. 

Ingals'  Powder  Blower,  as  indicated  by  figure  1510,  consists  of  four  small 
glass  tubes  with  a  compressing  bulb  and  connecting  rubber  hose.  Two 
tubes  are  straight,  one  being  flattened  to  throw  a  fan-shaped  stream.  The 
other  tubes  are  curved,  one  for  the  naso-pharynx  and  larynx,  the  other  for 
the  posterior  nares.  The  powder  may  be  stored  in  any  open  receptacle, 
but  preferably  in  a  short  wide-mouthed  bottle.  By  rotating  the  proximal 
ends  of  the  glass  tubes  in  the  powder  mass,  a  sufficient  quantity  of  the  latter 
may  be  loosely  pressed  within  the  lumen  of  the  tube  for  a  single  applica- 
tion. It  is  well  adapted  for  the  use  of  patients. 

Throat  Brushes. 

Medicaments  may  be  applied  to  the  throat  by  brushes  attached  to  long 
stems  or  handles. 


Figure  1511.    Bent  Quill  Brush. 

The  Bent  Quill  Brush,  displayed  in  figure  1511,  is  the  ordinary  form  of 
quill  throat  brush.  It  consists  of  a  camel's  hair  pencil  of  large  size,  the 
quill  bent  at  an  angle  of  about  135°  and  attached  to  a  slender  handle. 


COTTON-HOLDING    FORCEPS. 


651 


The   Wire   Throat   Brush,   portrayed  by  figure  1512,  is  a  camel's  hair 
brush  of  large  size  attached  to  a  slender  wire.      The  latter  at  its  proximal 


Figure  1512.      Wire  Throat  Brush. 


end  is  provided  with  two  rings,  by  means  of  which  it  may  be  securely  held. 
The  wire  is  flexible,  so  that  it  may  be  bent  to  any  desired  form. 

Cotton-Holding  Forceps. 

Various  fibrous  absorbents  may  be  employed  to  convey  medicaments  to 
diseased  parts.  They  may  be  held  in  the  jaws  of  forceps  or  other  forms 
of  clamps. 


Figure  1513.     Cohen's  Pharyngeal  Cotton  Carrier. 

Cohen's  Pharyngeal  Cotton  Carrier,  as  delineated  in  figure  1513,  is  a 
double-crossing  spring  forceps  about  8  inches  in  length,  with  slightly  curved 
blades.  The  inner  margins  of  the  blade  terminals  are  serrated.  The 
instrument  is  intended  either  for  making  applications  by  saturated  masses 
of  absorbent  cotton,  or  to  be  used  as  a  swab  to  remove  secretions. 


Figure  1514.     Elsberg's  Cotton-Holding   Forceps. 


Elsberg's  Cotton-Holding  Forcess,  as  traced  in  figure  1514,  are  of  slender 
design,  about  1 1  inches  in  length,  provided  with  separable  blades  and  catch 
handles.  The  instrument  is  curved  at  its  proximal  end  at  an  angle  of 
about  125°.  The  jaws  are  serrated,  with  mouse-tooth  tips,  the  whole  being 
so  shaped  as  to  firmly  hold  a  pledget  of  cotton  or  other  material. 


Figure  1515.    Cohen's  Cotton-Holding  Forceps. 


Cohen's  Cotton-Holding  Forceps,  as  may  be  seen  by  referring  to  figure 
1515,  are  of  three  designs,  comprising  instruments  for  laryngeal,  pharyngeal 
and  naso-pharyngeal  applications.  They  are  of  the  spring-forceps  type  with 
long  slender  blades,  the  jaws  of  which  are  supplied  with  four  teeth,  two 
upon  each  side.  Holes  or  openings  are  provided  in  each  jaw  to  receive 


CU 


652 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


the  teeth  on  the  opposite  side,  and  with  them  masses  of  cotton  or  gauze  may 
be  firmly  held  without  danger  of  detachment.  Slide  catches  of  the  inclined 
plane  pattern  permit  adjustment  to  masses  of  varying  thickness.  Design 
"A"  is  suitable  for  pharyngeal,  "B"  for  naso-pharyngeal,  and  "C"  for 
laryngeal  applications. 

Caustic  Applications. 

Chemical  caustics  may  be  applied  by  means  of  various  instruments. 
They  differ  in  design  according  to  the  nature  of  the  caustic  to  be  applied. 
While  glass  rods  and  cotton  carriers  are  frequently  employed  for  this  pur- 
pose, special  instruments  called  caustic  applicators  are  generally  preferred 


Figure  1516.     McCoy's  Applicator. 


McCoy's  Applicator,  as  traced  in  figure  1516,  consists  of  a  slender  silver 
probe,  surrounded  by  a  spiral  silver  wire  sheath,  the  whole  arranged  to 
be  curved  to  any  desired  shape.  The  probe  is  attached  to  a  fixed  handle, 
the  whole  forming  an  instrument  about  1 1  or  12  inches  in  length.  The 
wire  sheath,  which  extends  from  the  distal  end  backward  over  the  probe  for 
about  4  inches,  is  attached  to  a  slender  tube,  the  tube  and  sheath  being 
caused  to  move  backward  and  forward  by  means  of  a  lever  in  the  handle 
controlled  by  a  spiral  spring.  The  point  of  the  probe  may  be  charged  with 
chromic  acid,  either  by  immersing  the  tip  in  mucilage  and  by  this  means 
engaging  the  acid  crystals,  after  which  they  may  be  melted  by  heating  in  a 
spirit  lamp  and  allowed  to  cool  in  the  form  of  a  bead,  or  the  tip  may  be 
heated  and  plunged  into  the  crystal  mass,  where  by  its  warmth  it  will  melt 
a  sufficient  quantity  of  acid  that,  as  in  the  former  case,  may  be  permitted 
to  cool,  thus  forming  a  bead.  This  pattern  is  also  used  in  post-nasal  and 
pharyngeal  affections. 


ELONGATED  UVULA. 

The  removal  of  a  portion  of  the  uvula  will  require  a  cocaine  applicator; 
tongue  depressor,  figures  1440  to  1445,  and  at  least  some  of  the  following: 
Tenaculum  or  tissue  forceps  for  holding  uvula;  scissors  for  excision  or 
uvulatome,  or  snare  for  removal  of  uvula;  gag  for  holding  mouth  open,  and 
clamp  for  arresting  hemorrhage. 

Wandless'  Cocaine  Applicator,  as  exhibited  in  figure  1517,  is  a  broad 
shallow  spoon  provided  with  a  flat  handle,  curved  so  that  the  hand  of  the 
operator  may  not  obstruct  the  field  of  vision.  It  is  employed  for  anesthetiz- 
ing the  uvula  by  partial  immersion.  The  bowl  is  about  ^  of  an  inch  in 
length,  $/8,  in  breadth  and  ^,  in  depth.  Direct  application  without  the  use 


ELONGATED    UVULA. 


653 


of  cotton  or  other  absorbent  substances  may  be  made  by  placing  a  small 
quantity  of  cocaine  solution  in  the  cup  and  holding  the  bowl  immediately 


Figure  1517.     Wandless'  Cocaine  Applicator. 

under  and  in  contact  with  the  uvula.  If  necessary,  a  tongue  depressor  may 
be  used  for  controlling  the  tongue.  Before  the  patient  attempts  to  swallow, 
the  instrument  should  be  withdrawn,  allowing  the  uvula  to  drag  over  the 
distal  lip  of  the  bowl,  that  any  adhering  excess  of  cocaine  may  be  dislodged 
and  thus  prevented  from  dropping  into  the  mouth.  One  or  two  applica- 
tions at  intervals  of  one  or  two  minutes  each  will  usually  be  sufficient  for 
complete  anesthesia. 

Tenaculum  and  Tissue  Forceps. 

These  may  be  of  the  same  patterns  employed  in  gynecological  surgery. 
A  tenaculum  with  a  longer  curved  hook  is,  however,  generally  preferred. 


Figure  1518.     Pratt's  Tenaculum. 

Pratt's  Tenaculum,  as  shown  by  figure  1518,  is  suitable  for  holding  the 
uvula  during  its  excision  with  scissors.  It  is  constructed  with  a  fine  point 
and  sharp  curve,  the  whole  being  about  7  inches  in  length. 

Scissors. 

While  the  tivula  may  be  excised  with  some  form  of  tenaculum  and  an 
ordinary  pair  of  curved-on-the-flat  scissors,  it  is  claimed  that  better 
results  may  be  obtained  with  a  special  instrument,  or  a  scissors  provided 
with  claws  or  other  means  for  grasping  and  firmly  holding  the  organ. 


Figure  1519.    C 


Curved-on-the-Flat  Scissors,  as  detailed  in  figure  1519,  may  be  employed 
in  this  operation.  In  order  to  avoid  injury  to  the  pharyngeal  vault,  the 
points  should  be  well  rounded.  Scissors  curved  on  the  edge,  with  the  inner 
blade  provided  with  a  hooked  end,  are  also  recommended. 


Figure  1520.    Uvula  Scissors  with  Claws 


Uvula  Scissors    with    Claws,    as    manifest    in    figure    1520,    consist    of 
ordinary  scissors  about  8  inches  in  length,  curved  on  the  flat.     Claws  are 


654 


SURGERY  OF  THE  MOUTH  ANt)  THROAT. 


attached  to  the  blades  and  shanks  in  such  a  manner  that  they  move  and 
actuate  with  the  blades.  They  are  placed  closely  against  the  inner  curve 
of  the  blades,  and  are  so  adjusted  that  when  the  scissors  are  closed,  the  ser- 
rated edges  of  the  clamps  are  in  close  contact  with  each  other.  In  use,  the 
concave  surface,  or  the  one  to  which  the  claws  are  attached,  should  be 
underneath,  that  the  claws  may  grasp  and  remove  the  separated  portion. 


Figure  1521.     Morgan's 
Uvula  Clamp. 


Figure  1522. 


Seller's  Uvula  Scissors,  as  illustrated  in  figure  1522,  differs  from  those  of 
ordinary  construction  in  that  one  blade  is  bent  at  a  right  angle  with  the 
long  axis  of  the  instrument.  This  is  used  as  a  retractor  to  prevent  the  scis- 
sors from  forcing  the  uvula  from  the  grasp  of  the  blades  while  the  latter 
are  being  closed.  Two  sets  of  claws  that  open  and  close  with  the  blades, 
serve  to  prevent  the  excised  fragment  from  dropping  into  the  larynx. 

TJvulatomes. 

Uvulatomes,  or  guillotines,  consist  of  sliding  knives  operated  either  by 
spring  or  thumb  and  finger  movement.  It  is  intended  that  the  operator 
shall  cause  the  uvula  to  fall  through  an  opening  in  the  blade,  where,  before 
it  can  be  retracted  by  the  palatal  muscles,  it  is  severed  either  by  releasing 
a  self-acting  spring  or  by  a  thumb  and  finger  movement. 


Figure  1523.    Mackenzie's  Uvulatome. 

Mackenzie's  Uvulatome,  as  depicted  in  figure  1523,  is  constructed  with 
two  blades,  one  fenestrated,  the  other  shaped  like  a  sliding  chisel,  so  adjusted 
that  by  pressure  any  soft  tissues  encircled  by  the  fenestra  may  be  excised. 
The  fenestra  is  dome  shaped,  its  straight  base  lying  at  an  angle  of  about 
100°  with  the  axis  of  the  instrument.  The  chisel  presents  a  cutting  sur- 
face that  has  an  angle  of  about  80°.  The  closing  of  the  moving  upon  the 
fixed  blade  resembles  the  closing  of  the  ends  of  a  trapezoid.  One  side  of 
the  uvula  is  first  severed,  complete  excision  being  gradually  secured  as  the 
cutting  blade  advances.  Automatically  closing  jaws  open  and  close  with  the 
sliding  of  the  blade,  thus  securing  against  slipping,  and  preventing  the  de- 
tached portion  from  dropping  into  the  larynx. 

Uvula  Snares. 

Snares  are  employed  by  many  operators  for  removing  elongated  uvulae, 
No.  5  piano  wire  being  used.  Ordinarily,  a  uvula  may  be  severed  in  this 
manner  by  a  thumb  and  finger  movement,  thus  saving  the  time  that  would 
be  required  if  the  instrument  were  operated  by  screw  power.  This  method 


ELONGATED    UVULA. 


655 


is  said  to  have  the  advantage  of  producing  less  hemorrhage  than  other 
means.  Any  of  the  heavier  snares,  described  by  figures  1705  to  1711,  will 
answer  for  this  purpose. 

Uvula  Clamps. 

Clamps  are  occasionally  required  for  arresting  hemorrhage  after  excision 
of  the  uvula.  They  must  necessarily  be  small  and  light,  and  so  made  that 
they  will  not  be  accidentally  detached. 

Morgan's  Uvula  Clamp,  as  displayed  in  figure  1521,  is  a  small,  short  ser- 
refin  with  broad  serrated  blades,  which  do  not  exceed  ^  of  an  inch  in  length 
by  y%  of  an  inch  in  breadth.  That  there  may  be  no  danger  of  the  instru- 
ment being  swallowed  should  it  become  detached,  an  opening  is  provided 
by  which  a  thread  may  be  attached. 

Mouth  Gags. 

Instruments  which  are  employed  to  keep  the  mouth  open  during  oper- 
ations are  of  patterns  varying  from  the  simple  screw  shown  in  figure  346, 
to  the  Whitehead  appliance  exhibited  in  figure  1525.  Such  patterns  as 
are  used  to  forcibly  open  the  mouth  will  be  found  described  by  figures  346 
to  349  in  the  chapter  devoted  to  Anesthesia.  Those  especially  advised  for 
intubation  will  be  found  illustrated  by  figures  1578  to  1580. 


Figure  1524.    Greene's  Mouth  Gag. 


Figure  1525.    Whitehead's  Mouth  Gag. 


Greene's  Mouth  Gag,  as  defined  in  figure  1524,  consists  of  two  steel 
blades,  each  attached  to  a  sliding  shaft.  These  shafts  resemble  half  of 
a  rod  split  by  longitudinal  section,  the  flat  faces  resting  together.  Each 
blade  is  provided  with  a  slot  of  the  same  shape  and  a  trifle  larger  than  the 
shafts  through  which  the  latter,  by  compression,  are  caused  to  pass.  A 
spiral  spring  placed  between  the  blades  tends  to  keep  the  latter  separated. 
One  of  the  shafts  at  its  posterior  margin  is  transversely  serrated,  thus  afford- 
ing means  for  fixation  at  any  given  point.  The  extremities  of  the  blades 
are  curved  at  an  angle  of  90°  with  the  handles,  and  have  suitable  indenta- 
tions to  receive  the  teeth. 

Whitehead's  Mouth  Gag,  as  shown  in  figure  1525,  combines  the  essen- 
tial features  of  a  gag  and  tongue  depressor.  It  consists  of  two  curved  jaws, 
hinged  at  their,  extremities  and  so  shaped  as  to  pass  across  the  face  just 
over  the  lips  of  the  patient.  Curved  posterior  projections  in  the  center  of 
each  blade  form  points  of  contact  for  the  incisors.  The  lower  blade  is  pro- 
vided with  an  extension  that  serves  as  an  efficient  tongue  depressor.  In  the 
better  instruments  it  has  an  extension  by  which  it  may  be  lengthened.  A 
spring  and  ratchet  enable  the  surgeon  to  secure  the  amount  of  depression 
desired.  Extension  of  the  apparatus  is  secured  by  two  lateral  ratchet  bars 
actuated  by  spiral  springs.  The  instrument  is  available  for  tedious  oper- 
ations where  permanent  fixation  for  a  considerable  time  is  required. 


656 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


Denhart's  Mouth  Gag,  as  illustrated  in  figure  1526,  consists  of  two 
blades,  the  extremities  of  which  are  curved  in  bow  form.  As  the  blades 
are  not  of  the  crossing  variety,  compression  of  the  handles  causes  a  spread- 


Figure  1526.    Denhart's  Mouth  Gag. 


Figure  1527.     Mason's  Mouth  Gag. 


ing  of  the  jaws.  Any  amount  of  dilatation  secured  may  be  maintained  by 
means  of  a  ratchet  bar  connecting  the  handles.  The  jaws  consist  of  chan- 
neled sections  facing  outward,  the  contact  surfaces  of  which  are  covered 
with  a  layer  of  lead  to  prevent  injury  to  the  teeth. 

Mason's  Mouth  Gag,  as  portrayed  in  figure  1527,  while  constructed  on 
the  same  principle  as  the  pattern  last  described,  is  smaller,  with  handles 
projecting  outward  and  spreading  arms  projecting  inward,  both  at  right 
angles  with  the  main  body  of  the  instrument.  Instead  of  a  ratchet  bar  a 
fly  nut  is  used  to  maintain  extension.  The  terminal  ends  of  the  levers  are 
smaller  and  roughened  on  their  external  margins  that  a  piece  of  soft  rubber 
tubing  may  be  firmly  held  as  a  cushion  to  prevent  injury  to  the  teeth. 


ENLARGED  FAUCIAL  TONSILS. 

The  treatment  of  enlarged  tonsils  will  require  a  tongue  depressor,  and 
in  some  cases  a  mouth  gag,  and  the  resort  to  some  one  of  the  following 
-methods:  Medicated  applications,  chemical  caustics,  galvano-cautery,  elec- 
trolysis, injections,  ecrasement  and  excision.  Either  of  the  two  latter 
methods  may  require  the  use  of  a  tonsil  hemostat. 

Medicated  Applications  may  be  made  with  sprays,  see  figures  1484  to 
1502;  powder  blowers,  figures  1505  to  1510;  cotton  carriers,  figures  1676  to 
1678,  or  brushes,  figure  1511. 

Chemical  Caustics  may  be  applied  by  suitable  applicators,  various  pat- 
terns of  which  are  described  by  figures  1516  and  1682  to  1686. 

Galvano-Cautery  may  be  secured  by  battery  and  electrodes,  as  described 
by  figures  487  to  543. 

Electrolysis  may  be  performed  with  a  battery  of  continuous  current  and 
suitable  needles,  all  of  which  are  described  by  figures  479  and  480. 

Injections. 

Injections  may  be  made  or  caustics  applied  with  a  hypodermic  syringe, 
as  described  on  page  190. 

Pynchon's  Syringe,  as  illustrated  in  figure  1528,  consists  of  a  metal  bar- 
rel and  plunger,  the  former  provided  with  an  extension  that,  including  the 
ring  handle,  forms  an  instrument  8  inches  in  length.  The  cap  covering  the 
distal  end  of  the  syringe  is  soldered  to  the  barrel,  thus  avoiding  the  use  of 


ENLARGED    FAUCIAL    TONSILS. 


(557 


the  leather  packing  commonly  employed  in  syringes  of  this  pattern.  To 
facilitate  its  use  with  one  hand,  it  is  provided  with  rings  attached  to  either 
side  of  the  extension.  It  is  supplied  with  two  needles,  differing  in  size. 


Figure  1528.    Pynchon's  Tonsil  Syringe. 

Ecrasement. 

This,  whether  intended  to  secure  partial  or  complete  extirpation,  maybe 
accomplished  with  snares  that  may  be  either  ordinary  (cold)  or  used  with 
the  electro-cautery. 

Snares. 

A  snare  is  well  adapted  for  the  removal  of  small  masses,  and  for  complete 
eneucleation.  While  the  heavier  nasal  snares,  as  described  by  figures  1706 
to  1711,  will  answer  this  purpose,  it  is  advisable  to  employ  special  instru- 
ments of  extra  strength. 


Figure  1529.    Hammond's  Tonsil  Snare. 


Hammond's  Tonsil  Snare,  as  explained  in  figure  1529,  is  much  heavier 
than  those  employed  for  nasal  operations.  It  consists  of  a  strong  steel  shaft 
terminating  in  a  steel  tube,  the  whole  being  about  10  inches  in  length  and 
bent  near  its  center  at  an  angle  of  about  135°.  The  end  of  the  tube  is  con- 
structed with  a  single  opening,  so  that  the  wire  loop  may  be  drawn  entirely 
within  the  lumen,  thus  securing  a  complete  division  of  the  tissues.  The  tip 
is  attached  to  the  shaft  proper  by  means  of  a  shoulder  and  slip  joint.  A  set 
screw  passing  through  the  base  of  the  tube  firmly  holds  the  wire  in  place 
until  after  its  adjustment  over  the  tonsil.  A  heavy  draw-bar,  to  which  long 
arms  are  attached,  and  to  which  the  wire  is  secured,  may  be  moved  back 
ward  and  forward  along  the  shaft.  The  arms  are  of  sufficient  length  that, 

42 


058  SURGERY    OF    THE    MOUTH    AND    THROAT. 

when  it  is  necessary  to  operate  quickly,  all  the  fingers  may  be  brought  into 
service  and  the  excision  made,  as  a  rule,  without  the  aid  of  screw  power. 

That  a  firm  grasp  may  be  secured,  the  handle  terminates  in  a  bell-shaped 
head  about  i  ^  inches  in  diameter.  The  instrument  is  supplied  with  a  screw 
and  fly  nut  having  four  arms,  by  means  of  which  great  power  can  be 
secured.  This  is  intended  for  use  only  in  cases  where  it  is  found  impos- 
sible to  sever  the  tissues  with  hand  and  finger  movement.  The  entire  instru- 
ment is  strongly  constructed  and  is  especially  adapted  for  this  operation. 
Ecrasement  possesses  the  advantage  of  being  attended  by  less  hemorrhage 
than  most  other  methods. 


Figure  1530.     Bosworth's  Tonsil  Snare. 


Bosworth's  Tonsil  Snare,  as  outlined  in  figure  1531,  consists  of  a  strong 
cylindrical  shaft  provided  with  a  handle,  sliding  collar  and  fly  nut.  The 
distal  end  of  the  shaft  is  bent  at  an  angle  of  135°,  and  is  provided  with  a 
detachable  canula  through  which  the  wire  forming  the  loop  is  actuated. 
The  handle  is  T-shaped  and  slightly  curved  outward.  The  sliding  collar  is 
supplied  on  its  upper  margin  with  a  semi-circular  finger  guard,  and  upon  its 
lower,  with  a  strong  projecting  bar,  by  which  contact  with  the  middle,  third 
and  fourth  fingers  is  secured.  The  instrument  thus  furnishes  a  grasp  for  the 
entire  hand,  enabling  the  operator  to  exercise  considerable  force.  If  the 
latter  be  insufficient,  it  may  be  supplemented  by  a  fly  nut  provided  with 
spokes,  by  which  any  desired  degree  of  force  may  be  secured.  The  wire  is 
arranged  to  extend  through  the  canula  and  body  of  the  shaft  along  the  slot 
previously  referred  to,  and  is  attached  to  the  sliding  collar,  where  firm  union 
may  be  secured. 

Snaring  Forceps. 

In  operations  by  ecrasement,  forceps  are  usually  required,  by  the  use 
of  which  the  tonsil  may  not  only  be  lifted  from  its  bed  and  held  during  the 
adjustment  of  the  loop,  but  may  also  be  used  to  assist  in  slipping  or  passing 
the  wire  over  the  mass  to  be  excised. 

Ingals'  Tonsil  Forceps,  as  outlined  in  figure  1531,  are  of  strong  construc- 
tion, about  8  inches  in  length,  and  the  jaws  are  broad  and  sharply  curved 
on  the  flat.  These  jaws  are  bowl-shaped,  about  ^  of  an  inch  in  length, 
by  y%  of  an  inch  in  breadth,  the  outer  or  lower  border  presenting  a  con- 
cave margin,  the  whole  being  so  shaped  as  to  firmly  grasp  the  tonsil. 
As  the  jaws  may  be  forced  or  crowded  down,  engaging  the  tonsil  from  top 
to  bottom,  if  the  wire  loop  be  placed  around  the  forceps  before  the  tonsil  is 


ENLARGED    FAUCIAL    TONSILS. 


659 


engaged,  the  smooth  external  blades  of  the  instrument  will  be  found  to 
assist  greatly  in  pressing  the  loop  downward  into  the  desired  position. 


Figure  1531.     Ingals'  Tonsil  Forceps. 


Byrne's  Tonsil  Forceps,  pictured  in  figure  1532,  is  a  light  slender  instru- 
ment about  8  inches  in  length  and  curved  on  the  flat.  Each  blade  of  this 
instrument  contains  a  triangular  fenestra,  the  enclosing  bars  of  which  are 
y±  of  an  inch  in  extent.  Two  sides  of  these  triangles,  facing  each  other, 


Figure  1532.    Byrne's  Tonsil  Forceps. 

are  armed  with  sharp  lateral  projecting  teeth,  five  upon  one  blade  and  six 
upon  the  other,  the  two  rows  interlocking.  This  instrument  is  intended 
not  only  to  firmly  grasp  the  tonsil,  but  to  assist  in  placing  the  wire  loop  of  a 
snare  in  the  same  manner  as  described  in  connection  with  the  pattern  of 
Ingals. 


Figure  1533.    Pynchon's  Volsellum  Forceps. 

Pynchon's  Volsellum  Forceps,  as  defined  in  figure  1533,  are  of  the 
spring-handle  pattern  with  shanks  curved  downward  on  the  edge,  each  ter- 
minating in  two  tenaculum-shaped  teeth.  They  are  employed  to  grasp  a 
tonsil  for  the  purpose  of  drawing  it  out  of  its  bed  for  operation.  Owing  to 
the  length  and  size  of  the  teeth,  it  may  be  used  to  advantage  when  friable 
tissues  are  encountered. 

Excision. 

This  may  be  effected  with  knife  or  scissors  and  volsellum  forceps,  or  ton- 
sillotome,  the  latter  being  usually  preferred. 

Knives. 

These  may  be  employed  in  cases  where  the  tonsil  is  flat  or  so  deeply 
embedded  between  the  pillars  as  not  to  be  easily  reached  by  other  instru- 
ments. 


Figure  1534.    Probe-Pointed  Bistoury. 

The  Curved  Probe-Pointed  Bistoury,  as  sketched  in  figure  1534,  exhibits 
the  form  of  knife  ordinarily  employed  for  this  purpose.  It  consists  of  a  bis- 
toury slightly  curved,  probe-pointed  and  with  a  cutting  edge  about  i^ 
inches  in  length. 


CGO 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


Scissors. 

These  should  be  curved  on  the  flat,  and  with  at  least  one  point  blunt  or 
well  rounded. 


Figure  1535.    Curved-on-the-Flat  Scissors. 

The  Curved-on-the-Flat  Scissors,  set  forth  in  figure  1535,  exhibit  a  form 
adapted  for  this  operation.  They  consist  of  a  long  round  point,  curved  on 
the  flat  pattern,  of  about  the  same  size  and  shape  as  those  used  in  gyneco- 
logical surgery. 

Volsellum  Forceps. 

Ordinarily,  all  operations  by  knife  or  scissors  are  performed  by  the  aid 
of  some  form  of  volsellum  forceps.  These  are  a  form  of  heavy  tenaculum 
forceps,  usually  curved  downward  on  the  flat.  The  jaws  may  consist  of 
one,  two  or  more  hooks.  They  are  employed  to  hold  the  tonsil  during 
excision  with  knife  or  scissors  and  to  remove  the  severed  portion. 


Figure  1530.     Rozer's  Volsellum  Forceps. 


Rozer's  Volsellum  Forceps,  as  drawn  in  figure  1536,  are  of  slender 
design,  about  8  inches  in  length,  and  with  blades  shaped  like  small  curved 
tenacula  with  sharp,  slender  points.  The  two  are  so  shaped  that  when  the 
instrument  is  closed,  a  small  loop  is  formed.  The  handles  are  provided 
with  catches.  This  pattern  is  one  of  the  most  delicate  designs  constructed 
for  this  purpose. 


Figure  1537.    Casselberry's  Volsellum 
Forceps. 

Casselberry's  Volsellum  Forceps,  as  they  appear  in  figure  1537,  are  about 
7^  inches  in  length,  and  differ  from  the  pattern  of  Rozer  in  being  con- 
structed with  more  slender  handles,  in  having  no  catch  and  in  having  two 
tenaculum- shaped  prongs,  upon  each  blade.  The  shank  of  the  instrument 
is  in  bayonet  form. 

Burrows'  Volsellum  Forceps,  as  defined  in  figure  1538,  consists  of  a  plain 
curved-on-the-flat  volsellum  forceps,  each  blade  being  provided  with  three 


ENLARGED    FAUCIAL    TONSILS.  601 

prongs  or  hooks.      The  instrument  is  sharply  curved,   the  blades  being 
almost  at  a  right  angle  with  the  handle. 


Figure  1538.    Burrows'  Volsellutn  Forceps. 

Tonsillotomes. 


These  consist  of  sliding  knives,  so  adjusted  as  to  excise  any  enclosed 
soft  tissues  with  a  single  stroke.  Many  forms  are  in  use,  the  mechanism 
of  which  may  be  studied  in  the  following  selections: 


Figure  1539.    Mathieu's  Tonsillotome. 

Mathieu's  Tonsillotome,  as  indicated  in  figure  1539,  is  perhaps  the  best 
known  and  most  largely  employed  of  all  the  patterns  of  this  class.  The  body 
of  the  instrument  consists  of  three  parts,  one,  the  inner,  sliding  backward 
and  forward  between  the  other  two,  the  three  being  bound  together  by 
suitable  clamps.  The  distal  ends  of  the  three  parts  are  enlarged  to  form 
oval-shaped  rings,  the  long  diameter  of  which  is  at  right  angles  with  the 
shaft  of  the  instrument,  thus  conforming  closely  to  the  usual  shape  of  the 
parts  requiring  excision.  The  inner  blade  is  controlled  and  operated  by 
means  of  finger  rings  placed  upon  both  sides  near  the  proximal  end.  A 
double-pointed  spear  extends  the  full  length  of  the  instrument  and  is  caused 
to  move  backward  and  forward  by  a  thumb  movement,  the  thumb  mean- 
while resting  in  a  ring  united  to  the  proximal  end  of  the  shaft  by  a  swivel 
joint.  This  spear  after  penetrating  the  tonsil,  by  the  adjustment  of  a  self- 
acting  lever,  is  caused  to  rise,  thus  lifting  or  drawing  the  engaged  part 
more  firmly  into  the  ring  of  the  instrument.  The  amount  of  this  retrac- 
tion may  be  regulated  by  screw  device.  When  ready  for  introduction,  the 
shaft  bearing  the  spear  is  withdrawn,  while  the  knife-shaped  ring  is  covered 
and  completely  surrounded  by  the  two  outer  ones.  After  the  instrument  is 
in  place,  the  spear  may  be  forced  forward  by  a  single  quick  movement,  the 
tonsil  pierced  and  retracted,  the  knife  liberated,  excision  completed  and 
the  detached  portion  firmly  held  by  the  spears  of  the  instrument.  The 
operation  is  practically  completed  by  contracting  or  closing  the  thumb  and 
fingers  of  the  engaged  hand. 

As  first  constructed,  the  spear  points  of  this  instrument  were  armed  with 
barbs,  it  being  supposed  that  this  was  necessary  in  order  to  prevent  the  de- 
tached portion  from  becoming  dislodged  and  possibly  swallowed  by  the 
patient.  This  was  a  dangerous  feature,  for,  after  once  engaging  the  tonsil, 
it  was  necessary  to  complete  the  operation,  no  matter  what  complication 
might  arise,  because  of  the  impossibility  of  withdrawing  the  barb-pointed 
spear.  As  it  has  been  found  that  considerable  force  is  necessary  to  remove 
the  detached  portion  of  a  tonsil  from  a  plain  spear,  the  barbs  are  unnecessary 
and  seldom  employed,  so  that  the  instrument  may  now  be  withdrawn  even 
after  the  perforation  of  the  tonsil  by  the  spear  points. 


662 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


By  a  peculiar  adjustment,  the  blade  of  this  instrument  is  not  liberated 
until  after  the  spear  points  have  perforated  the  tonsil  and  the  retracting 
movement  is  completed,  neither  can  the  instrument  be  operated  without 
using  the  spear  point,  as  the  use  of  this  is  necessary  to  release  the^blade 
from  its  sheath  or  covering. 

The  entire  length  of  this  instrument  is  from  10  to  u  inches.  Ordinarily 
they  may  be  purchased  in  five  sizes,  with  fenestrse  of  the  following  dimen- 
sions : 

No.  o,  $i  by  %. 


inch  by  J&. 
by  i  inch. 


Q-fc^   •B3    ||t  |   ^»0:£RMIWfc**2 
--;         f 


Figure  1540.     Ermold's  Tonsillotome. 

Ermold's  Tonsillotome,  as  sketched  in  figure  1540,  is  more  simple  in 
construction,  and  yet  quite  as  efficient  as  the  ordinary  pattern  of  Mathieu. 
Instead  of  two  fixed  blades  between  which  a  knife  is  caused  to  actuate,  it 
is  constructed  with  two  knife  blades  each  of  the  same  size  and  shape,  one 
fixed  and  the  other  movable.  Both  are  provided  with  flat  inner  surfaces 
that  rest  in  close  contact  and  a  double-pointed  spear,  operated  by  a  thumb- 
ring  as  in  the  original  pattern.  The  latter  instead  pf  being  raised  by  the 
action  of  a  sliding  lever,  passes  across  the  face  of  an  inclined  plane,  secur- 
ing the  necessary  amount  of  elevation  as  it  moves  forward.  The  blades 
throughout  their  length  are  prevented  from  sliding  upon  each  other  by  a 
pin  that  rests  in  a  hole  in  the  opposite  blade.  The  forward  movement  of 
the  spear  shaft  releases  the  blades,  thus  enabling  the  operator  to  retract  the 
moving  blade,  and  secure  excision  of  the  engaged  tissues. 


Figure  1541.    Casselberry's  Tonsillotome. 

Casselberry's  Tonsillotome,  as  shown  in  figure  1541,  is  also  a  modifica- 
tion of  the  pattern  of  Mathieu.  Its  principal  difference  is  that  the  prox- 
imal ring  is  attached  in  a  bayonet  form,  so  that  the  protruding  end  of  the 
thumb  may  not  intercept  the  field  of  vision,  and  that  the  spear  and  all  the 
mechanism  connected  with  it  are  omitted.  This  furnishes  a  greatly  sim- 
plified instrument.  It  is  manufactured  in  two  sizes  with  f enestrae,  ^  by  yz 
and  i  inch  by  ^  respectively. 

Aubry's  Tonsillotome,  as  traced  in  figure  1542,  differs  from  the  pattern 
of  Mathieu  in  the  action  of  its  cutting  blade.  Instead  of  a  loop  moving 
backward  and  catching  the  imprisoned  tonsil  between  the  blade  edge  and 
the  rear  portion  of  the  fenestra,  this  instrument  presents  a  sliding  curved 


ENLARGED    FAUCIAL    TONSILS. 


663 


bistoury,  hinged  upon  one  end  and  moved  by  retraction  of  the  other.  All 
the  advantages  of  a  sliding  knife  blade  are  secured  in  the  operation  of  this 
appliance.  In  all  other  respects  the  instrument  is  a  duplicate  of  the 
pattern  above  referred  to. 


Figure  1542.    Aubry's  Tonsillotome. 

Bishop's  Tonsillotome,  as  set  forth  in  figure  1543,  is  a  modification  of 
Mackenzie's,  differing  from  the  latter  principally  in  that  the  handle  is  fold- 
ing and  the  long  diameter  of  the  fenestra  is  in  a  line  with  the  shaft.  It 
consists  of  two  plates,  one  sliding  upon  the  other,  the  two  held  together  by 
a  post  passing  through  a  slot.  A  handle  is  attached  to  the  lower  blade  at 


Figure  1543.     Bishop's  Tonsillotome. 

nearly  a  right  angle.  This  blade  at  its  distal  end  is  widened  and  has  an 
oval  fenestra.  Surrounding  this  blade  from  side  to  side  and  around  the 
tip  is  a  collar  containing  a  horizontal  groove  into  which  the  cutting  blade 
may  be  forced.  The  blade  is  thin  with  a  flat  lower  and  beveled  upper  sur- 
face, its  distal  margin  being  sharpened  to  a  fine  edge.  It  is  actuated  by 
thumb  and  finger  movement.  After  excision,  the  edges  of  the  severed 
portion  will  be  held  by  the  blade  within  the  margins  of  the  groove  pre- 
viously referred  to,  enabling  the  operator  to  withdraw  the  fragment  with  the 
instrument.  The  length  of  the  blade  is  usually  about  6%  inches.  It  is 
made  in  two  sizes,  with  fenestrse,  i  inch  by  i^  and  ^  by  i  inch. 

Billings'  Tonsillotome,  as  depicted  in  figure  1544,  is  a  combination  of 
some  of  the  principles  previously  described  in  connection  with  a  self-grasp- 
ing double  tenaculum,  the  action  of  which  is  controlled  by  the  forward 
movement  of  the  cutting  blade.  The  body  of  this  instrument  consists 
of  two  parts,  the  lower  part  being  provided  with  finger-rings  at  its  prox- 
imal end,  its  distal  end  being  enlarged  so  as  to  form  the  necessary  fenestra. 
The  lateral  border  of  this  portion  is  turned  so  as  to  form  slots  or  guides 


664 


SURGERY    OF    THE    MOUTH    AND    THROAT. 


upon  each  side  in  which  the  knife  blade  actuates.  The  blade  differs  from 
that  of  Mackenzie  in  being  egg-shaped  or  longer  upon  one  side  than  upon 
the  other.  When  the  blade  is  withdrawn,  the  tenacula  are  separated  and  rest 


Figure  1544.    Billings'  Tonsillotome. 

upon  either  side  of  the  fenestra.  With  the  forward  movement  of  the  blade 
they  are  drawn  together,  and  as  the  blade  progresses,  they  are  retracted 
or  turned  upward,  holding  the  severed  portion  until  the  instrument  is 
withdrawn. 

Tonsil  Hemostats. 

Hemostats  or  compressors  for  controlling  hemorrhage  of  the  tonsils, 
usually  consist  of  some  form  of  clamp  forceps  so  constructed  that  one  blade 
may  rest  immediately  upon  the  bleeding  surface,  while  the  other,  located 
externally,  makes  direct  pressure  over  the  tonsil  mass. 


Figure  1545.    Stork's  Tonsil  Hemostat. 


Stork's  Tonsil  Hemostat,  as  shown  by  figure  1545,  consists  of  a  pair  of 
heavy  forceps,  about  8  inches  in  length,  the  blades  of  which  are  so  shaped 
that  they  will  encompass  the  jaw  and  cheek  of  the  patient  in  such  a  man- 
ner that  the  bleeding  parts  may  be  compressed  by  pressure.  This  is 
accomplished  by  locating  one  blade  within  the  laryngeal  cavity,  while  the 
other  is  placed  externally.  The  blades  are  each  supplied  with  pads,  a 
smaller  one  resting  upon  the  external  surface,  and  the  other,  oval  in  form, 
and  swinging  on  a  pivot  arranged  to  fit  accurately  upon  the  bleeding 
surface  without  reference  to  the  direction  of  its  long  angle  or  to  the  plane 
of  the  incised  surface.  A  hinged  bolt  with  fly  nut  and  proper  stays  is 
attached  to  the  blades  between  the  pivot  and  the  distal  end  and  so  adjusted 
that  after  the  requisite  amount  of  pressure  is  secured,  the  blades  may  be 
locked  and  firmly  held  in  position.  By  the  aid  of  slip-joints,  the  ring 
handles  may  then  be  removed,  and  the  instrument  materially  shortened 
This  is  a  matter  of  convenience  in  cases  where  it  is  necessary  for  the  clamp 
to  remain  in  place  for  any  length  of  time.  During  the  adjustment  of  the 
forceps  the  handles  are  held  in  place  by  screw  stops. 

Clendenin's  Tonsil  Hemostat,  as  exhibited  in  figure  1546,  consists  of  two 
tonsil  pads,  the  contact  surfaces  of  which  are  held  in  firm  approximation 
by  arms  controlled  by  a  coiled  spring.  At  least  one  of  the  arms  should  be 


ENLARGED    LINGUAL    TONSIL. 


supplied  with  a  sponge  surface  that  may  be  employed  for  the  administration 
of  fluid  styptics.  As  in  the  pattern  previously  described,  one  of  the  clamps 
is  placed  external  to,  the  other  upon  the  bleeding  surface. 


Figure  1546.    Clendenin's  Tonsil  Hemostat. 


ENLARGED  LINGUAL  TONSIL. 

Hypertrophy  of  this  organ  may  be  reduced  by  measures  similar  to  those 
prescribed  for  the  faucial  tonsils.  The  methods  in  common  vogue  necessi- 
tate the  employment  of  some  one  of  the  following: 

Chemical  caustics,  figures  1516  and  1682;  electro-cautery,  figures  487  to 
543;  snare,  figures  1529  and  1530;  scissors,  and  scarificators. 

Scissors. 

Those  required  for  this  operation  need  not  differ  from  the  pattern 
described  by  figure  1535.  An  ordinary  curved-on-the-flat  uterine  scissors 
with  suitable  volsellum  forceps  answer  every  purpose.  Special  scissors, 
provided  with  claws,  are  recommended  by  some  authors. 


Figure  1547.    Casselberry's  Lingual  Tonsil  Scissors. 

Casselberry's  Lingual  Tonsil  Scissors,  as  portrayed  in  figure  1547,  do 
not  differ  in  general  construction  from  some  of  the  uvula  scissors,  described 
by  figures  1520  to  1522.  Their  distinctive  feature  is  the  shape  of  the 
blades,  which  are  sharply  curved  on  the  flat,  that  they  may  closely  fit  or  con- 
form to  the  shape  of  the  tonsil  incision.  With  this  instrument  it  is 
intended  that  complete  excision  may  be  secured  with  a  single  application. 
Toothed  jaws  that  move  with  the  scissors  blades  are  employed  not  only  to 
hold  the  tonsil  during  excision  but  to  remove  the  fragment  after  separation. 

Scarificators. 

Scarification  may  require  some  form  of  knife  or  needle  with  which  to 
puncture  the  cysts,  after  which  the  fluid  contents  may  be  expressed  by  press- 
ure on  the  parts.  The  instruments  generally  employed  for  this  operation 


666  SURGERY  OF  THE  MOUTH  AND  THROAT. 

are  called  lancets.  Generally  they  are  of  two  varieties,  either  plain  or 
concealed.  In  the  absence  of  a  special  knife,  a  curved  bistoury  may  be 
employed,  provided  the  blade  be  protected,  as  shown  by  figure  598. 


Figure  1548.    Tobold's  Lance-Pointed  Laryngeal  Knife. 

Tobold's  Lance,  as  drawn  in  figure  1548,  is  a  long  slender  steel  shaft, 
curved  at  an  angle  of  90°,  and  terminating  in  a  small  lancet-shaped  "knife, 
sharp  upon  both  edges,  having  a  breadth  not  to  exceed  3  millimeters. 
The  curved  portion  of  the  blade  is  about  3  inches  in  length,  while  the 
straight  portion  of  the  shaft  together  with  the  handle  is  about  9  inches 
long. 


Figure  1549     Tobold's  Concealed  Lancet. 


Tobold's  Concealed  Lancet,  as  delineated  in  figure  1549.  is  similar  in 
general  form  to  the  plain  knife,  last  described  It  differs  from  the  latter, 
however,  in  being  provided  with  a  sheath  so  arranged  that  by  pressure 
upon  a  thumb-ring,  the  knife  blade  may  be  protruded  or  uncovered  at  the  tip 
of  the  instrument.  A  slender  tube,  to  which  finger  holds  are  attached,  is 
curved  to  the  desired  shape,  the  knife  being  mounted  upon  an  elastic  shaft 
that  is  caused  to  move  backward  and  forward  within  the  tube.  The  point 
is  kept  concealed  by  an  elastic  spring,  the  compression  of  which  forces  the 
knife  forward  exposing  it  for  use. 


REMOVAL  OF  FOREIGN  BODIES. 

The  removal  of  foreign  bodies  from  the  pharynx,  larynx  and  trachea  by 
extraction  or  expulsion  through  the  natural  passages  will  require : 

Tongue  depressor,  figures  1440  to  1445,  illuminating  apparatus,  figures 
1446  to  1470;  probe  and  extracting  instruments. 

Suitable  Light  may  be  obtained  by  employing  the  apparatus  described 
by  figures  1446  to  1470.  In  many  cases  diffused  light  will  be  found  su- 
perior, particularly  in  locating  small  and  delicate  articles,  the  color  of 
which  may  be  similar  to  the  parts  upon  which  they  rest. 

Probes  of  any  flexible  pattern,  like  figure  1018,  will  be  found  useful  for 
the  location  and  dislodgment  of  foreign  bodies. 


REMOVAL    OF    FOREIGN    BODIES. 


667 


Foreign  Body  Extractors. 

These  must  vary  according-  to  the  location,  size  and  nature  of  the  foreign 
body.  Usually  they  consist  of  some  form  of  forceps.  Apparatus  designed 
for  use  in  the  esophagus  will  be  found  described  in  a  chapter  devoted  to 
operations  on  that  organ.  • 

Forceps  for  extracting  foreign  bodies  have  been  constructed  in  multiple 
forms,  many  being  designed  to  fill  the  requirements  of  special  cases. 
Experience  has  demonstrated  that  puzzling  complications  are  more  the 
result  of  position  and  location  than  of  the  character  or  size  of  the  foreign 
substance.  We  shall,  therefore,  present  only  some  of  the  general  instru- 
ments employed  for  this  purpose. 


Figure  1550.     Buck's  Throat  Forceps. 


Buck's  Throat  Forceps,  as  indicated  in  figure  1550,  consists  of  a  slender 
forceps,  about  8  inches  in  length,  the  jaws  of  which  are  serrated  for  about 
i  %  inches  and  curved  on  the  edge,  so  that  the  tip  is  about  i  inch  lower 
than  the  axis  of  the  handle.  It  is  adapted  for  removing  foreign 
bodies  from  the  fauces  and  upper  portion  of  the  larynx.  This  pattern  is 
particularly  useful  where  substances  are  lodged  in  the  aryteno-epiglottic 
folds  or  the  pyriform  sinus. 


Figure  1551.    Leonard's  Throat  Forceps 


Leonard's  Throat  Forceps,  as  described  in  figure  1551,  differ  from  the 
pattern  last  described  in  being  much  heavier,  curved  on  the  edge  and  with 
handles  bent  downward,  that  the  hand  of  the  operator  may  not  obstruct  the 


Luer's  Antero-Posterior  Alligator  Jaw  Forceps. 

field  of  vision.     The  distance  from  the  handle  to  the  point  of  second  curv- 
ature is  8  inches,  while  the  curved  laryngeal  portion  is  2  %  inches  in  length, 


668 


SURGERY    OF    THE    MOUTH    AND    THROAT. 


The  jaws  are  doubly  concave,  and  have  serrated  margins  about  ^  of  an 
inch  in  extent. 

Luer's  Alligator  Throat  Forceps,  as  outlined  in  figures  1552  and  1553, 
differ  from  each  other  only  in  the  direction  of  the  forceps  bite.  As 
indicated  by  their  name  one  opens  and  closes  laterally,  and  the  other 


Luer's  Lateral  Alligator  Jaw  Forceps. 

antero-posteriorly.  This  movement  is  effected  by  a  lever  and  toggle  joint. 
The  total  length  of  the  forceps  is  about  n  inches,  the  curved  laryngeal 
portion  being  about  3^  inches  long.  The  handles  are  supplied  with 
catches. 


Figure  1554.    Cohen's  Trachea  Foreign  Body  Forceps. 

Cohen's  Trachea  Foreign  Body  Forceps,  as  portrayed  in  figure  1554,  are 
slender  in  construction,  bulb-pointed  and  shaped  so  as  to  be  readily  ad- 
mitted into  the  trachea  through  a  tracheal  incision. 


Figure  1555.    Roe's  Tracheal  Forceps. 

Roe's  Tracheal  Forceps,  as  represented  in  figure  1555,  consist  of  a  slen- 
der spiral  tubular  shaft  about  9  inches  in  length  surrounding  a  copper  rod, 
the  latter  terminating  in  jaws  adapted  for  grasping  foreign  bodies.  The 
opening  and  closing  of  these  jaws  is  controlled  by  sliding  the  spiral  tube 
backward  and  forward  along  the  central  portion.  This  movement  is  im- 
parted by  means  of  a  hinged  lever,  one  end  of  which  is  ring-shaped.  Three 
patterns  of  detachable  jaws  accompany  each  instrument ;  one  f enestrated 
and  semi-circular  for  grasping  round  bodies,  a  biting  forceps  with  serrated 
margins,  and  one  slender  and  with  mouse-teeth  for  grasping  large  masses 
of  soft  material,  such  as  pieces  of  meat,  etc. 


REMOVAL    OF    TUMORS,    FOREIGN    GROWTHS,    ETC.  669 


REMOVAL  OP  TUMORS,  FOREIGN  GROWTHS,  ETC. 

These  may  be  treated  by  various  methods,  among  which  are :  Chemical 
caustics  and  topical  applications,  galvano-cautery,  ecrasement,  avulsion, 
crushing,  incision,  excision,  nearly  all  of  which  will  require  the  use  of  a 
syringe  for  local  anesthetic. 

Chemical  Caustics  may  be  employed  by  means  of  such  instruments  as 
are  described  by  figures  1516  and  1324.  Many  such  patterns  are  flexible, 
and  may  thus  be  used  for  the  deeper  portions  of  the  larynx. 

Galvano-Cautery  Points  for  laryngeal  use,  will  be  found  described  by 
figures  494  to  543. 

Ecrasement  employed  in  the  removal  of  pedunculated  growths,  may  be 
secured  by  means  of  a  suitable  snare.  As  these  instruments  are  more 
largely  employed  in  diseases  of  the  nose  and  naso-pharynx,  they  will  be 
found  illustrated  in  a  chapter  devoted  to  that  subject. 

Avulsion. 

This  may  be  secured  by  the  use  of  snares,  ecraseurs,  forceps,  etc. 
Snares  and  Ecraseurs  will  be  found  fully  illustrated  in  the  chapter  de- 
voted to  surgery  of  the  nose  and  naso-pharynx. 

Tumor  Forceps. 

These  are  often  called  polypus  forceps.  They  are  of  various  patterns, 
but  usually  have  serrated  jaws.  In  addition  to  the  patterns  here  described, 
a  number  will  be  found  included  in  the  sets  of  instruments  described  by 
figures  1566  to  1568. 


Figure  1556.     Fauvell's  Tumor  Forceps. 


Fauvell's  Tumor  Forceps,  as  illustrated  by  figure  1556,  are  full  curved  and 
about  ii  inches  in  length,  the  tips  of  the  blades  extending  about  3^  inches 
below  the  handle  line.  The  instrument  is  heavy  and  the  blades  so  shaped 
as  to  close,  each  past  the  other,  thus  giving  to  the  instrument  as  much 
grasping  power  as  is  possible,  considering  that  in  its  construction  it  is  neces- 
sary to  place  the  pivot  near  the  handles.  The  jaws  are  concave,  fenestrated 
and  have  sharply  serrated  margins.  Each  is  provided  with  two  teeth, 
which,  when  the  forceps  jaws  are  closed,  fit  into  corresponding  openings  on 
the  opposite  side,  thus  securing  a  firm  grasp  upon  any  soft  tissues.  This 
instrument  is  also  used  for  removing  foreign  bodies. 

Crushing. 

This  consists  in  bruising  or  lacerating  the  tumor  tissues,  so  that  sloughing 
ensues,  or  that  they  may  be  destroyed  by  the  resulting  inflammation.  This 
may  be  performed  with  almost  any  of  the  strong  tumor  forceps. 


670 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


Mackenzie's  Throat  Tumor  Forceps,  as  exhibited  by  figures  1557  and 
1558,  differ  in  construction  only  in  that  one  is  curved  upon  the  edge,  the 
other  upon  the  flat :  one  opens  from  side  to  side  and  the  other  antero-posteri- 


Figure  1557.    Mackenzie's  Antero-Posterior 
Laryngeal  Forceps. 


Figure  1558.     Mackenzie's  Lateral  Throat  Forceps. 


orly.     Both  are  of  heavy  design,  with  doubly  concave  jaws  an  inch  in  extent 
and  with  sharply-serrated  margins. 

Incision. 

Removal  by  morcellement  may  be  secured  by  means  of  scissors,  knives 
and  forceps. 

Scissors  for  morcellement  do  not  differ  from  those  shown  by  figures  927 
to  929.  They  should  be  provided  with  at  least  one  sharp  point. 

Knives. 


Figure  1559.  Tobold's  Laryngeal  Kniv 


Knives  for  incising  tumors  in  the  larynx  and  upper  portion  of  the  trachea 
require  to  be  constructed  with  long  handles,  curved  shanks  and  small  slen- 
der blades. 


REMOVAL    OF    TUMORS,     FOREIGN    GROWTHS,    ETC. 


671 


Tobold's  Laryngeal  Knives,  as  traced  in  figure  1559,  are  of  three  pat- 
terns. Two  are  curved  bistouries  with  probe  points  and  concave  cutting 
surfaces,  one  cutting  outward  or  backward,  the  other  inward  or  forward. 
The  third  pattern  is  a  plain  spear-point  knife  with  double  cutting  edge. 
They  are  constructed  with  long  handles  and  steel  shafts,  the  latter  termina- 
ting in  the  blade.  The  straight  portion  of  each,  including  the  handle,  is 
about  8^  inches  in  length,  and  the  curved  portion  about  3  inches  in  length. 

Excising'  Forceps. 

These,  which  are  sometimes  called  biting,  cutting  and  gouging  forceps, 
are  usually  some  variety  of  forceps  so  adjusted  as  to  punch  or  bite  out  a 
portion  of  a  tumor  mass. 


Figure  1560.    Mackenzie's  Cutting  Forceps. 


Mackenzie's  Cutting  Forceps,  as  sketched  in  figure  1560,  are  of  heavy 
construction,  with  jaws  curved  at  a  right  angle  with  the  handle.  The  inner 
surfaces  of  the  jaws  are  cup  or  trough-shaped  with  sharp  cutting  margins. 
The  depressions  are  about  ^  of  an  inch  in  length  and  2  millimeters  deep. 
The  straight  portion  is  about  8  and  the  curved  section  about  3  inches  in 
length. 


Tobold's  Laryngeal  Cutting  Forceps. 


Tobold's  Laryngeal  Cutting  Forceps,  as  shown  in  figure  1561,  are  con- 
structed with  a  compound  lever,  so  adjusted  that  the  instrument  occupies  but 
little  space,  even  when  the  jaws  are  fully  dilated.  The  latter  are  narrow 
and  cup  shaped,  with  cutting  surfaces  extending  around  both  sides  and  end. 


672 


SURGERY    OF    THE    MOUTH    AND    THROAT. 


As  the  curved  or  laryngeal  portion  of  this  instrument  is  about  3^  inches  in 
length,  it  may  be  utilized  to  advantage  for  removing  tumor  masses  below 
the  vocal  cords. 

Excision. 

Tumors  may  be  cut  away  en  masse  by  means  of  scissors  and  guillotines. 

Scissors. 

These  are  constructed  with  long  sweeping  curves.   They  are  of  two  vari- 
eties, with  vertical  and  horizontal  cutting  edges. 


Figure  1562.    Waldenburg's  Throat  Scissors. 


Waldenburg's  Throat  Scissors,  as  pictured  in  figure  1562,  have  straight 
cutting  blades,  with  the  shaft  of  the  instrument  curved  upon  the  edge.  The 
blades  are  slender,  with  a  cutting  surface  of  about  i  yz  inches.  The  short 
angle  of  the  instrument  is  about  3^  inches  in  length,  while  the  handle  is 
about  8  inches  long.  They  are  of  heavy  construction,  the  handles  possessing 
sufficient  power  to  cut  any  tissues  that  may  be  found  necessary. 


Figure  1563.    Tobold's  Horizontal  Cutting  Scissors. 


Tobold's  Laryngeal  Scissors,  as  outlined  in  figure  1563,  consist  of 
heavy  scissors  provided  with  a  double  joint.  By  this  we  mean  that  the  in- 
strument is  supplied  with  two  pivots  or  hinges.  The  instrument  is  curved 
upon  the  edge,  terminating  in  two  short  scissors  blades  bent  at  a  right  angle 
to  the  direction  of  the  shaft  at  the  point  of  the  angle.  By  this  it  will  be 
seen  that  the  scissors  are  arranged  to  cut  horizontally  or  in  a  cross  section. 
The  cutting  surfaces  of  the  blades  are  about  7  millimeters  in  extent  and 
are  arranged  to  slip  past  each  other  a  sufficient  distance  to  ensure  severing 
any  included  tissues.  Notwithstanding  its  complicated  design,  the  instru- 
ment is  of  strong  construction  and  well  calculated  to  accomplish  all  work 
required. 

Tobold's  Polypus  Scissors,  as  defined  in  figure  1564,  are  designed  for 
making  vertical,  antero-posterior  incisions  within  the  trachea.  They  are  con- 
structed with  a  single  fixed  blade,  the  terminal  portion  of  which  is  curved 
forward  at  nearly  a  right  angle.  The  movable  blade  is  of  the  combined 
lever  type,  so  arranged  that  it  moves  downward  by  handle  pressure.  The 


REMOVAL    OF    TUMORS,     FOREIGN    GROWTHS,    ETC. 


G73 


two  blades  arc  so  adjusted  that  they  cut  with  a  chisel-like  stroke.  Two  pro- 
jecting hooks  are  provided  on  the  lower  blade  to  catch  and  hold  any  parts 
that  may  be  excised. 


Figure  1564.    Tobold's  Vertical  Cutting  Scissors. 


Guillotines. 

These,  as  employed  in  surgery,  usually  consist  of  a  loop  or  ring-shaped 
knife  arranged  for  excising  any  tissues  that  may  be  included  in  the  fenestra. 


figure  1565.    Mathieu's  Guillotine. 


Mathieu's  Guillotine,  as  drawn  in  figure  1565,  consists  of  two  small  fenes- 
trated  blades,  whose  flat  surfaces  rest  together,  one  being  fixed,  the  other 
movable.  The  latter  is  attached  to  a  strong  spiral  spring  which  furnishes 
the  retracting  and  excising  force.  The  shaft  of  the  instrument  consists  of  a 
spiral  rod  contained  within  a  tube.  The  rod  to  which  the  moving  blade  is 
attached  may  be  extended  by  pushing  forward  upon  a  collar  that  surrounds 
the  shaft  near  the  proximal  end  of  the  instrument.  The  loop  is  passed  over 
the  growth  to  be  excised.  To  facilitate  this,  the  blades  are  swiveled,  so  that 
they  may  be  turned  in  any  desired  direction.  When  in  position  for  oper- 
ating, the  movable  blade  is  held  by  means  of  a  ratchet  catch,  which  may  be 
released  by  pressure  upon  a  small  lever  supplied  for  that  purpose.  Two 
small  prongs,  arranged  to  contact  the  severed  portion,  insure  the  removal  of 
the  latter.  This  is  probably  the  best  of  the  many  patterns  of  automatic 
guillotines. 

Krause's  Guillotine  and  Laryngeal  Set,  as  detailed  in  figure  1566,  con- 
sists of  a  tube,  forceps  and  snares  arranged  for  use  with  either  a  straight 
rigid  tube,  or  one  that  may  be  curved  to  any  desired  form.  In  addition  to 
this,  a  guillotine  curved  for  laryngeal  use  is  provided.  The  instrument  prac- 
tically consists  of  a  sliding  shaft  arranged  to  a  fixed  handle,  the  latter 

43 


674 


SURGERY    OF    THE    MOUTH    AND    THROAT. 


provided  with  a  swi  veled  thumb-ring  at  its  proximal  end.  The  central  rods, 
the  distal  ends  of  which  form  the  guillotine,  forceps,  etc.,  are  arranged  for 
attachment  to  a  sliding  bar,  the  movement  of  which  is  controlled  by  a  spi- 
ral spring  and  two  finger-rings.  When  properly  adjusted,  the  guillotine 


Figure  1566.    Krause's  Guillotine  and  Laryngeal  Set. 

may  be  operated,  the  forceps  jaws  closed,  and  the  snare  refracted  by  a  sim- 
ple thumb  and  finger  movement. 

The  straight,  fixed  shape  is  constructed  for  use  either  with  the  tube  for- 
ceps or  snares.  The  former  consists  of  a  slender  rod  terminating  in  forceps- 
shaped  jaws,  the  latter  self-opening  and  provided  with  sharp  serrated  teeth, 
the  grasping  power  of  .which  is  increased  by  three  prongs,  two  upon  one 
side  and  one  upon  the  other,  each  fitting  into  openings  on  the  opposite  side 
of  the  blade.  This  shaft  is  flexible  and  may  be  used  either  straight  or 
curved. 

The  guillotine  blades  are  two  in  number,  of  the  same  size,  but  differing 
in  the  shape  of  the  cutting  edges,  one  being  beveled  upon  the  right,  the 
other  upon  the  left  side,  each  presenting  a  flat  surface  upon  one  side.  These 
blades  are  about  12  millimeters  in  diameter  with  fenestrae  of  8  millimeters 
in  diameter.  The  adjustment  is  such  that  after  the  guillotine  is  slipped 
over  or  around  the  mass  to  be  excised  by  thumb  and  finger  pressure,  the 
blade  may  be  drawn  within  the  guard  surrounding  it  and  the  parts  severed 
by  pressure  upon  the  cutting  edges.  The  snare  rods  are  two  in  number, 
each  in  duplicate.  The  snare  wire  is  attached  to  the  terminal  end  of  the 
rod  by  passing  backward  and  forward  through  openings  provided  for 
that  purpose.  They  may  be  used  either  in  connection  with  the  forceps 
tubes  or  the  guillotine  guard. 

Combined  Instruments  for  Avulsion,  Excision,  Ecrasement,  Etc. 

Sailer's  Guillotine,  Scarifier  and  Tube  Forceps,  as  they  appear  in  figure 
1567,  consist  of  a  handle  to  which  may  be  attached  elastic  spiral  shafts  in 
which  are  operated  flexible  rods  that  terminate  in  instruments  of  various 
forms.  The  rod  and  shaft  being  flexible,  they  may  be  curved  to  any  desired 
shape.  The  central  rods  extend  into  the  handle  where  they  are  firmly 
fixed  by  means  of  a  set  screw.  The  shafts  are  adjusted  to  press  against  a 
spiral  spring  so  arranged  that  by  means  of  a  trigger  or  lever  they  may  be 
pushed  forward  and  used  either  to  force  tissues  against  the  cutting  edge  of 
the  guillotine  blade,  to  compress  the  jaws  of  the  forceps  or  to  shield  the 


REMOVAL    OF    TUMORS,    FOREIGN    MATTER,    ETC. 


675 


lancet  point.  The  guillotine  consists  of  a  small  circular  knife  having  an 
external  measurement  of  about  12  millimeters  with  an  opening  or  fenestra 
about  8  millimeters  in  diameter.  It  is  intended  that  the  ring  shall  be  slipped 


Seller's  Guillotine,  Scarifier  and  Tube  Forceps 


over  or  around  the  tissues  to  be  severed,  excision  being  accomplished 
for  forcing  forward  the  shaft  of  the  instrument,  thus  crowding  the  tissues 
against  the  cutting  surface  of  the  blade. 

The  forceps  are  operated  through  a  shaft  having  a  circular,  funnel- 
shaped  tip.  The  forceps  open  by  spring  movement  when  pushed  forward. 
Upon  retraction  they  are  drawn  into  the  tube  and  thus  forcibly  closed. 

The  scarifier  consists  of  a  spear-pointed  blade  with  double-cutting  edge. 
It  is  arranged  to  be  concealed  within  the  tube  by  pressure  upon  the  trigger. 
Upon  releasing  the  latter,  the  shaft  retracts,  thus  exposing  the  knife. 


Figure  1568.     Schroetter's  Set  of  Laryngeal  Tube  Forceps,  Scissors,  etc. 

Schroetter's  Laryngeal  Set,  as  indicated  in  figure  1568,  consists  of  a 
universal  handle  to  which  may  be  attached  any  one  of  the  seven  tubes 
shown  in  the  illustration.  The  shafts  of  these  tubes  are  attached  to  the 
handle  by  means  of  a  set  screw.  Each  shaft  is  provided  with  an  inner  rod 
that  may  be  attached  to  a  sliding  bar  supplied  with  a  thumb-piece,  by  means 
of  which  it  may  be  moved  backward  and  forward  as  desired.  The  for- 
ceps blades  are  so  constructed  that  when  the  shaft  to  which  they  are  attached 
is  pushed  forward,  they  expand  or  open.  By  retracting  the  thumb-piece  in 
the  handle,  the  blades  are  withdrawn  within  the  terminal  end  of  the  canula, 


676  SURGERY    OF    THE    MOUTH    AND    THROAT. 

thus  forcing  the  blades  to  close.  The  handle  of  this  instrument  is  in  pistol 
form  slightly  curved  to  one  side.  The  tubes  not  only  possess  a  laryngeal 
curve,  but  are  also  curved  to  the  right,  that  the  hand  of  the  operator  may 
not  obstruct  the  field  of  vision.  The  set  comprises : 

One  plain  serrated  forceps  that  may  be  given  either  a  lateral  or  an 
antero-posterior  motion. 

One  serrated  forceps  with  horizontal  bite ;  the  jaws  are  so  constructed 
that  they  may  be  turned  in  any  direction.  This  pattern  is  particularly 
adapted  for  removing  flat  substances  that  rest  upon  or  within  the  vocal 
cords,  and  are  so  located  that  they  present  a  broad  surface  to  forceps  of 
ordinary  form. 

Serrated  forceps  with  oblique  bite.  This  differs  from  the  pattern  last 
described,  in  that  the  direction  of  the  bite  can  not  be  changed. 

Scissors  with  convex  cutting  edge. 

Porte- caustique.  The  terminal  end  or  caustic  tip  of  this  is  silver.  It 
has  a  lateral  as  well  as  an  end  opening.  As  the  opening  may  be  turned  in 
any  direction,  it  has  a  universal  application. 

The  two  remaining  tubes  are  arranged  for  use  with  knives  and  scis- 
sors (three  patterns  of  the  former  and  one  of  the  latter),  any  of  which 
may  be  attached  by  a  screw  joint. 

TREATMENT  OF  STRICTURE, 

Laryngeal  stricture  or  stenosis  and  occlusion  by  foreign  bodies,  from 
whatever  cause,  may  usually  be  relieved  by  some  one  of  the  following 
methods:  Dilatation,  divulsion,  tracheotomy,  thyreoidotomy,  laryngec- 
tomy,  or,  in  case  of  malignant  tumor,  laryngectomy. 

Dilatation. 

This  may  be  either  gradual  or  rapid.  Gradual  dilatation  may  be  secured 
by  solid  plugs  or  tubes.  The  latter  are  preferred  because  they  do  not 
interfere  with  respiration.  For  this  reason  they  may  be  allowed  to  remain 
in  situ  without  tracheotomy.  These  tubes  are  generally  called  intubation 
tubes  and  the  procedure  for  their  introduction  is  known  as  intubation. 

Solid  Plugs  or  Bougies. 

These  consist  of  acorn  or  long  bulb-shaped  dilators,  constructed  in  a  se- 
ries of  sizes.  As  they  effectually  close  the  air  passage,  thev  can  be  used  only 
after  tracheotomy. 


Figure  1569.     Schroetter's  Metal  Bougies. 

Schroetter's  Metal  Bougies,  as  depicted  in  figure  1569,  consist  of  a  series 
of  twenty  cylindrical  metal  plugs  of  various  sizes  and  an  instrument  for  in- 
troduction. The  dilators  comprise  sizes  suitable  for  all  stages  of  dilatation. 
Each  is  constructed  with  a  small  projecting  tip  at  one  end  provided  with  a 
lateral  opening,  by  means  of  which  the  plug  is  attached  to  the  introducing 
instrument.  The  latter  consists  of  a  long  shaft  provided  with  an  inner 


TREATMENT    OF    STRICTURE. 


677 


stylet.     This  terminates  at  its  distal  end  in  a  slender  hook  of  proper  size  to 
engage  the  opening  in  the  dilator  tip  previously  referred  to. 

Intubation. 

Tubular  dilators  for  intubation  may  be  employed  in  cases  of  closure  of 
the  glottis.  The  introduction  and  maintenance  in  the  larynx  of  a  specially 
constructed  tube  may  relieve  or  prevent  stenosis.  This  operation,  together 
with  the  necessary  instruments,  is  the  original  invention  of  Bouchon,  who 
first  brought  it  to  the  attention  of  the  public  in  1858.  Later  on,  O'Dwyer, 
of  New  York,  independently  devised  and  perfected  the  instruments,  so 
that  either  his  or  some  modified  form  are  generally  employed. 

While  this  method  is  often  adopted  in  diphtheria,  it  is  applicable  in  cica- 
tricial  stenosis  only  when  a  tube  may  be  introduced  of  sufficient  size  to 
maintain  respiration.  In  such  cases,  however,  if  the  opening  be  too  small, 
it  may  be  enlarged  with  some  one  of  the  instruments  described  in  this  section 
under  the  sub-head  of  divulsion. 

The  instruments  necessary  for  intubation  consist  of:  Tubes  of  various 
sizes;  scale  for  determining  proper  size  of  tube;  introducer  for  placing  tube 
in  position ;  extractor  for  removal  of  tube ;  gag  to  prevent  closure  of  mouth ; 
membrane  forceps;  mouth  shield,  and  finger  cots. 

An  exception  to  this  list  is  the  instrument  of  Ferroud  which  is  used  for 
both  introduction  and  extraction. 

Intubation  Tubes. 

These  consist  of  short  rigid  tubes  introduced  into  the  trachea  for  the 
purpose  of  maintaining  an  open  passage  in  cases  of  stenosis  or  occlusion. 


Figure  1570.     O'Dwyer's  Intubation  Tubes. 


Figure  1571.     Ferroud's  Intubation  Tubes. 


O'Dwyer's  Intubation  Tubes,  as  traced  in  figure  1570,  consist  of  a  series 
of  six,  graded  in  sizes  suitable  for  patients  twelve  years  of  age  and  under.  As 
now  constructed,  they  consist  of  an  ovoid  cylinder  bulging  slightly  at  its  cen- 
ter, the  lower  half  somewhat  larger  than  the  upper  and  provided  with  a 
nearly  circular  head  having  a  somewhat  rounded  upper  margin.  This  head 
is  so  shaped  as  to  rest  evenly  on  the  ventricular  bands  when  the  tube  is  in 
situ.  That  it  may  not  interfere  with  the  action  of  the  glottis,  the  head  is 
constructed  with  a  short  perpendicular  diameter.  The  body  of  the  tube  is 
made  as  narrow  as  possible  through  its  lateral  or  short  diameter,  that  it  may 
not  produce  undue  pressure  on  the  vocal  cords.  The  opening  through  the 
tube  is  oval,  the  lumen  having  a  slight  posterior  curve  at  its  upper  extrem- 


678  SURGERY  OF  THE  MOUTH  AND  THROAT. 

ity.  The  anterior  margin  of  the  head  is  perforated  for  the  insertion  of  a 
cord  or  thread.  This  may  be  required  for  prompt  extraction  of  the  tube  in 
case  it  is  by  mistake  introduced  into  the  oesophagus,  or  becomes  occluded  by 
detached  fragments  of  membrane  or  other  accident.  Each  tube  is  provided 
with  an  obturator  jointed  in  the  center,  extending  through  the  lumen  and 
projecting  from  each  end.  The  lower  portion  presents  a  round,  bulbous 
appearance,  thus  filling  the  lumen  of  the  tube-opening  and  rendering  it  more 
easy  of  introduction. 

The  upper  end  is  provided  with  a  female  thread,  by  means  of  which  it 
is  attached  to  the  introducing  instrument.  The  joint  in  the  center  of  the 
obturator  is  to  assist  in  its  removal  otherwise  the  vertical  distance  neces- 
sarily occupied  by  this  obturator  while  being  removed,  would  render  extrac- 
tion difficult.  These  obturators  should  fit  closely  within  the  tube  lumen, 
where  they  are  held  by  lateral  pressure  upon  the  inner  walls.  They  should 
not  fit  too  tightly  or  otherwise  the  surgeon  would  find  it  difficult  to  detach 
and  remove  the  obturator  after  the  tube  is  in  situ. 

Formerly,  these  tubes  were  manufactured  from  metal.  They  are  now, 
however,  constructed  from  hard  rubber  with  a  metallic  tubular  lining.  The 
six  tubes  ordinarily  found  in  an  intubation  set  vary  in  length  from  \y2  to 
2^  inches.  Usually,  tubes  for  adult  use  may  be  obtained  of  various  sizes, 
ranging  from  3  to  4  inches  in  length  with  corresponding  diameters. 

Ferroud's  Intubation  Tubes,  as  sketched  in  figure  1571,  are  a  modifica- 
tion of  the  O'Dwyer  pattern.  They  are  constructed  of  metal,  plated  with 
gold  and  highly  burnished.  The  differences,  though  slight,  are  claimed 
as  advantages  by  their  inventor.  The  lower  end  of  the  tube  is  beveled  later- 
ally at  an  angle  of  45°,  so  that  one  side  is  longer  than  the  other.  This 
gives  a  pointed  form  to  the  tube  ending,  which  makes  its  introduction  easy. 
The  wedge-shaped  end  is  rounded  to  a  blunt  point.  The  lumen  of  the  tube 
is  straight  throughout  its  entire  length.  The  upper  margin  of  the  head  is 
funnel-shaped  to  assist  in  directing  the  extracting  instrument  into  the  tube 
cavity.  In  other  respects,  the  tubes  are  practically  the  same. 

Measurement  Scales. 

These  consist  of  devices  employed  to  measure  and  thus  select  the  proper 
size  of  tube  required  for  each  case. 


Figure  1572.     O'Dwyer's  Improved  Scale.  Figure  1573.    O'Dwyer's  Original  Scaie. 

O'Dwyer  Scale,  as  shown  in  figure  1572,  exhibits  an  improved  form. 
It  consists  of  a  flat  piece  of  metal  provided  with  six  openings,  each  of  suf- 
ficient size  to  admit  one  of  the  tubes  constituting  the  set ;  in  other  words, 
the  size  of  the  opening  corresponds  with  the  external  size  of  the  tube  at  its 
center.  The  average  age  of  patient  to  which  the  individual  tube  should  be 
applied  is  stamped  upon  the  scale  opposite  the  corresponding  opening. 

O'Dwyer's  Original  Scale,  as  illustrated  in  figure  1573,  differs  from  the 
improved  pattern  in  measuring  the  length  of  the  tube  instead  of  its  di- 
ameter. The  corresponding  size  is  marked  in  figures,  as  previously  de- 
scribed. In  selecting  a  tube  of  proper  size  by  this  method,  the  head  is  in- 
cluded in  the  measurement. 


TREATMENT    OF    STRICTURE. 


679 


Tube  Introducers. 

These  consist  of  handles  or  other  devices  employed  to  control  and  direct 
an  intubation  tube,  that  it  may  be  correctly  placed  within  the  trachea. 


Figure  1574.    O'Dwyer's  Introducer. 


O'Dwyer's  Introducer,  as  displayed  by  figure  1574,  consists  of  a  shaft  and 
handle,  the  former  at  its  distal  end  sharply  curved  to  a  right  angle.  The 
shaft  is  double  with  an  outer  sliding  tube  controlled  by  a  thumb-piece,  by 
means  of  which  it  may  be  moved  backward  and  forward.  Near  its  distal 
end.  and  at  a  point  corresponding  with  the  bend  of  the  shaft,  the  tube  is 
composed  of  a  spiral  wire,  rendering  it  elastic,  so  that  when  pushed  forward, 
it  may  pass  over  or  along  the  curved  portion  of  the  shaft.  This  elastic  por- 
tion terminates  in  a  two-pronged  fork,  one  upon  each  side  of  the  shaft  end- 
ing. The  end  of  the  shaft  is  provided  with  a  male  screw  by  which  it  may 
be  attached  to  the  obturator  in  the  tube,  previously  described.  This  instru- 
ment is  employed  for  introducing  the  tube.  After  the  latter  is  in  proper 
position,  by  pushing  forward  the  thumb-piece,  the  tube  may  be  detached 
from  the  obturator,  after  which  the  latter  may  be  withdrawn. 


Figure  1575.    Waxham's  Introducer  and  Obturator. 


Waxham's  Introducer  and  Obturator,  as  shown  by  figure  1575,  is  a  modi- 
fication of  a  pattern  secured  by  the  author  in  Germany,  the  name  of  the 
original  inventor  being  unknown.  It  consists  of  an  obturator  with  an  elas- 
tic shaft  attached  to  a  fixed  handle,  the  latter  provided  with  means  for  the 
dislodgment  of  the  tube  after  the  latter  is  in  situ.  Much  annoyance  has 
been  caused  in  the  past  by  the  screw  joint  necessitated  in  obturators  of  the 
O'Dwyer  pattern.  This  is  due  not  only  to  the  wearing  away  of  the  thread 
on  the  introducing  instrument,  but  frequently  when  duplicate  tubes  are 
purchased  with  which  to  complete  sets  from  which  one  or  more  tubes  have 
been  lost,  it  happens  that  such  obturators  do  not  properly  fit  the  introducer 
already  on  hand.  An  attempt  to  use  such  a  tube  only  results  in  destroying 
the  thread,  after  which  the  tube  will  not  remain  in  its  proper  position,  for 
it  may  turn  partially  around  or  present  the  posterior  surface  next  to  the 
handle.  In  the  device  here  described  the  obturator  forms  a  portion  of  the  in- 


680 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


strument  shaft,  a  screw  joint  being  unnecessary.  By  a  series  of  clamps 
and  slip  joints,  the  obturator  and  dislodging  shaft  are  coupled  together  in 
such  a  way  that  any  one  of  the  obturators  may  be  attached  to  the  instrument 
and  easily  removed.  All  parts  are  separable  for  cleansing. 

Tube  Extractors. 

These  consist  of  forceps-like  instruments  with  diverging  blades  or 
other  means  for  engaging  and  removing  an  intubation  tube  from  the 
trachea. 


Figure  1576.    O'Dwyer's  Intubation  Tube  Extractor 


O'Dwyer's  Extractor,  for  the  removal  of  intubation  tubes,  as  drawn  in 
figure  1576,  consists  of  a  forceps-shaped  device  by  means  of  which  the 
upper  portion  of  the  tube  lumen  may  be  engaged  by  the  separating  of  the 
instrument  jaws  and  a  lateral  pressure  secured  firm  enough  to  dislodge 
and  withdraw  the  tube.  It  consists  of  a  handle  and  shaft,  the  latter  curved 
at  nearly  a  right  angle.  The  bent  portion  is  about  2  inches  in  extent, 
while  the  body  of  the  instrument  is  about  8%  inches  long.  One  blade  is 
fixed,  practically  consisting  of  an  extension  of  the  handle  and  shank.  The 
second,  or  upper  blade,  is  hinged,  and  is  constructed  in  the  form  of  a  com- 
pound lever,  the  lever  itself  being  short  and  so  arranged  that  downward 
pressure  on  the  upper  blade  separates  the  jaws  of  the  instrument.  The 
latter  are  small,  and  somewhat  bulbous,  with  roughened  external  surfaces 
so  arranged  that  a  firm  grip  upon  the  lumen  of  the  tube  may  be  secured. 


Ferroud's  Introducer  and  Extractor. 

Ferroud's  Introducer  and  Extractor,  as  indicated  in  figure  1577,  is  more 
simple  in  construction  than  the  pattern  of  O'Dwyer.  It  takes  the  place  of 
both  introducer  and  extractor,  and  with  the  tubes  described  by  figure  1571, 
requires  no  obturators.  These  are  marked  advantages  cla'imed  for  this 
pattern.  This  instrument  consists  of  a  handle  and  two  blades,  one  fixed, 
the  other  jointed  like  a  forceps.  The  jaws  of  the  forceps-like  portion  are 
curved  upon  the  edge  at  an  angle  of  90°.  Closure  of  the  handles  opens  or 
spreads  apart  the  jaws  of  the  instrument.  Near  its  proximal  end  the  mov- 
able blade  is  curved  upward,  its  tip  being  bent  downward  at  a  right  angle 


TREATMENT    OF    STRICTURE. 


681 


with  the  shaft.  This  portion  of  the  blade  passes  through  a  slot  in  the 
shank  of  the  fixed  blade,  where  it  is  held  in  any  desired  position  by  a 
ratchet.  The  anterior  and  posterior  margins  of  the  jaws  are  finely  serrated, 
that  when  introduced  into  the  lumen  of  the  tube  and  expanded,  a  sufficient 
grasp  will  be  established  to  enable  the  operator  to  either  introduce  or  extract 
the  tube.  The  blades  are  united  by  a  screw  joint  that  they  may  be  sepa- 
rated for  cleansing. 

Mouth  Gags. 

These  instruments  for  forcibly  opening  the  mouth,  will  be  found 
described  by  figures  346  to  349.  The  patterns  here  shown  are  those  which 
have  been  particularly  advised  for  intubation.  While  any  good  pattern  of 
mouth  gag  may  be  employed  for  this  operation,  the  following  have  been 
found  most  desirable  by  experts: 


Figure  1578.    Denhardt's  Gag. 

Denhardt's  Gag,  as  shown  in  figure  1578,  consists  of  two  blades,  jointed 
near  their  center,  the  jaws  curved  in  a  hook  form,  the  handles  straight 
and  so  adjusted  that  by  closing  them  the  jaws  are  separated.  The  tips  of 
the  jaws  are  each  provided  with  small  plates  wide  enough  to  accommodate 
the  teeth  of  the  patient,  and  provided  with  flanges  that  they  may  not  slip 
from  position.  Usually  these  plates  are  supplied  with  faces  of  lead  that 
danger  of  breaking  the  teeth  may  be  avoided.  A  ratchet  catch  provided 
with  a  self-acting  spring  secures  the  instrument  at  any  degree  of  extension 
that  may  be  desired.  The  length  of  this  instrument  is  usually  about 
inches. 


Figure  1579.    Waxham's  Mouth  Gag. 


Waxham's  Mouth  Gag,  as  illustrated  by-  figure  1579,  consists  of  two 
blades  hinged  like  those  last  described,  but  only  half  curved.  The  instru- 
ment is  shaped  so  that  when  the  jaws  are  resting  in  the  angle  of  the  mouth, 
the  handles  will  extend  over  the  ear.  The  tips  of  the  blades  are  provided 
with  jaws  similar  to  those  in  the  pattern  of  Denhardt.  An  oblong 
metallic  slide,  extending  over  both  handles,  is  used  as  a  stop.  The  exter- 
nal surface  of  both  handles  being  serrated,  this  slide  may  be  used  to 
maintain  any  desired  degree  of  extension.  The  length  is  about  5^ 
inches. 


682 


SURGERY    OF    THE    MOUTH    AND    THROAT. 


Ferroud's  Mouth  Gag,  as  defined  by  figure  1580,  consists  of  a  hand  plate 
provided  with  two  rings  and  a  central  bar,  the  latter  sharply  curved  upon 
itself.  Its  tip  is  triangular,  and  its  outer  surface  is  so  shaped  that  it  may 
be  placed  between  the  teeth  and  there  held  as  long  as  desired.  By  forcing 


Figure  1580.    Ferroud's  Mouth  Gag. 

the  wedge  well  back  in  the  angle  of  the  jaw,  the  latter  may  be  opened  to 
any  desired  extent.  Flanges  upon  either  side  of  the  jaw-piece  will  keep 
the  teeth  from  slipping  from  the  instrument.  Its  length  is  about  3^ 
inches.  Pynchon  has  modified  this  gag  by  employing  a  wedge  of  soft 
rubber,  firm  enough  to  secure  extension  and  still  soft  enough  to  secure 
good  contact  with  no  risk  of  injuring  the  teeth. 

Membrane  Forceps. 

These,  according  to  Waxham,  should  form  a  part  of  every  set  of  instru- 
ments for  intubation.  They  are  employed  to  remove  detached  portions  of 
membrane  in  cases  where  they  occlude  the  lumen  of  the  tube. 


Figure  1581.    Waxham-Cusco's  Forceps 


Waxham-Cusco's  Membrane  Forceps,  as  portrayed  in  figure  1581,  are 
curved  upon  the  edge  and  provided  with.two  pivots,  one  upon  the  straight, 
the  other  upon  the  curved  portion  of  the  blades.  The  straight  portion  of 
the  handle  of  the  moving  blade  is  united  with  the  curved  section  by  a 
pin  and  slot  movement,  thus  forming  a  compound  lever.  As  the  separa- 
tion of  the  jaws  does  not  necessitate  a  separation  at  the  point  where  the 
instrument  passes  through  the  vocal  cords,  it  is  admirably  adapted  for 
removing  false  membrane  and  foreign  bodies  that  may  be  lodged  in  the 
lower  portion  of  the  larynx.  The  length  of  the  straight  portion  is  about 
S}4  inches  and  that  of  the  curved  portion  3  inches. 


TREATMENT    OF  STRICTURE. 

Mouth  Shields. 

These  are  employed  as  a  precaution  against  direct  infection.  In  the 
absence  of  a  regularly  prepared  shield  or  a  respirator,  a  pad  may  be  pro- 
vided by  folding  several  thicknesses  of  antiseptic  gauze  and  tying  it  over 
the  mouth. 


Figure  1582.     Waxham's  Shield. 

Waxham's  Shield,  as  delineated  in  figure  1582,  consists  of  several  thick- 
nesses of  absorbent  gauze  constructed  in  the  form  of  an  oblong  pad.  Its 
author  advises  its  use  in  all  cases  where  it  is  necessary  to  introduce  intuba- 
tion tubes  in  diphtheria. 

Sets  of  Instruments  for  Intubation. 


t  Figure  15*5.     O'Dwyer's  Set  of  Instruments  for  Intubation. 

O'Dwyer's  Instruments  for  Intubation,  as  set  forth  in  figure  1583,  com- 
prise 6  intubation  tubes  with  obturators,  figure  1570;  introducer,  figure 
1574,  extractor,  figure  1576;  Denhardt's  mouth  gag,  figure  1578;  and  scale, 
figure  1572.  All  are  contained  in  a  metal  case. 


Intubation. 


Figure  1585.    Ferroud's  Set  of  Instruments  for 
Intubation. 


Waxham's  Instruments  for  Intubation,  as  shown  in  figure  1584,  include 
5  intubation  tubes  with  obturators,  figure  1570;  introducer,  figure  1575; 
extractor,  figure  1576;  mouth  gag,  figure  1579;  false  membrane  forceps, 


684 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


figure  1581;  mouth  shield,  figure  1582,  and  scale,  figure  1572.  All  are 
contained  in  a  metal  case. 

Ferroud's  Set  of  Instruments  for  Intubation  contains :  6  intubation  tubes, 
figure  1571;  introducer  and  extractor,  figure  1577;  mouth  gag,  figure  1580, 
and  scale,  figure  1572.  It  is  well  represented  in  figure  1585. 

Rapid  Dilation  may  be  secured  by  means  of  instruments  constructed 
with  two  or  more  blades  so  arranged  that  they  may  be  separated  or 
expanded  by  screw  power. 

Laryngeal  Dilators. 

These  usually  consist  of  two  or  more  blades,  arranged  in  such  a  manner 
that  they  may  be  spread  or  dilated  by  mechanism  contained  within  the 
handle.  They  are  employed  to  relieve  stenosis. 


Mackenzie's  Laryngeal  Dilator. 


Mackenzie's  Laryngeal  Dilator,  as  shown  in  figure  1586,  consists  of  a 
shaft  about  7  inches  in  length,  terminating  in  three  short  heavy  blades, 
each  about  i%  inches  long,  and  bent  at  a  laryngeal;  that  is,  at  nearly  a 
right  angle.  The  body  of  the  instrument  consists  of  a  tube  flattened  at  its 
proximal  end,  in  the  center  of  which  a  shaft  is  caused  to  revolve  by  means 
of  a  fly-nut  and  screw  power.  The  third  blade  of  the  instrument  is 
attached  to  this  shaft  and  is  therefore  fixed.  The  others  are  arranged  to 
be  pushed  forward  or  outward  by  means  of  the  screw  power  referred  to,  and 
at  the  same  time  to  dilate  laterally.  This  instrument  when  in  action, 
therefore,  is  a  triangular  dilator. 

Divulsion. 

Divulsion  necessitates  the  use  of  a  cutting  instrument  by  means  of  which 
cicatricial  bands  may  be  incised.  Usually  some  form  of  concealed  knife  is 
employed. 


Figure  1587.    Whistler's  Cutting  Laryngeal  Dilator. 


Whistler's  Cutting  Laryngeal  Dilator,  as  portrayed  in  figure  1587,  is  an 
acorn-shaped  bulb,  having  a  blade  concealed  within  it  and  a  lever  by  means 
of  which  the  blade  is  protruded  when  desired.  The  act  of  passing  the  bulb- 
ous tip  places  any  existing  cicatricial  bands  on  a  stretch,  thus  rendering 


TREATMENT    OF    STRICTURE.  685 

them  tense  and  suitable  for  division.  The  shaft  of  the  instrument  is  hollow 
and  contains  a  flexible  rod,  to  which  is  attached  the  cutting  blade.  The  latter 
is  controlled  by  a  spring  located  within  the  handle,  the  tendency  of  which 
is  to  keep  the  blade  within  the  bulb.  This  movement,  however,  is  con- 
trolled by  the  lever,  as  shown  in  the  illustration. 

Tracheotomy,  Laryngotomy,  Laryngectomy,  Thyreoidotomy,  Etc. 

These  operations,  regardless  of  the  cause,  whether  made  through  the 
laryngeal  cartilages  or  tracheal  rings,  will  require  nearly  all  of  the  fol- 
lowing: 

Minor  operating  instruments,  described  on  pages  270  to  275. 

Tracheotomy  tube  for  maintaining  artificial  opening. 

Tracheal  dilator  for  dilating  wound  for  tube  introduction. 

Trachea  retractors  for  spreading  wound  margins. 

Trachea  forceps  for   removing  false  membrane  below   tube    opening. 

Infra-glottic  mirror. 

Tracheotomy  Tubes. 

Tracheotomy  tubes  consist  of  curved  canulas  so  constructed  as  to  form 
an  external  connection  with  the  trachea  through  an  anterior  artificial  open- 
ing. While  they  are  usually  curved  to  the  arc  of  a  quadrant,  angular  ones 
have  been  used.  They  are  manufactured  from  both  metal  and  hard  rub- 
ber The  latter  material  is  objected  to,  not  only  because  it  is  fragile,  but 
because  it  requires  the  construction  of  a  tube  with  unnecessarily  thick  walls. 
Owing  to  the  nature  of  the  material,  the  inner  canula  frequently  becomes 
fixed  by  dried  mucus,  and  not  infrequently  one  or  both  of  the  tubes  are 
broken  in  an  effort  to  separate  them.  They  will  always  answer,  however, 
for  temporary  use,  and,  as  they  are  inexpensive,  the  surgeon  can  usually 
afford  to  keep  an  assortment  of  them  on  hand  to  meet  special  emergencies. 
If  the  case  demands  the  use  of  a  permanent  tube,  a  silver  one  of  the  same 
size  can  be  purchased. 

Occasionally  patterns  are  constructed  with  the  canula  divided  laterally 
through  its  long  axis,  that  by  dilatation  it  may  conform  to  openings  of 
various  sizes.  These  patterns  are  objectionable,  because  tissues,  by  lateral 
pressure,  crowd  or  bulge  into  the  opening,  where  they  frequently  become 
eroded.  Others  are  manufactured  with  valves,  so  that  while  inspiration  is 
secured  through  the  tracheal  opening,  expiration  is  maintained  through  the 
natural  passages. 

All  tracheotomy  tubes  should  be  carefully  sterilized  before  introduction, 
and  should  be  removed  frequently  during  the  first  twenty-four  hours  after 
the  operation.  Some  writers  claim  that  should  be  done  as  often  as  once  an 
hour,  in  order  to  see  that  the  tube  is  kept  free  from  mucus.  As  long  as  they 
are  worn,  these  instruments  should  be  kept  free  from  accumulations  of  mem- 
brane, mucus,  etc.  Several  patterns  of  tubes  are  constructed  with  trocars, 
by  means  of  which  what  is  sometimes  termed  "rapid  tracheotomy  "may  be 
performed.  These  will  also  be  described  under  this  heading. 

Trousseau's  Tracheotomy  Tube,  as  shown  in  figure  1588,  is  the  ordinary 
double  tracheotomy  tube,  the  pattern  usually  employed  for  this  operation. 
This  consists  of  twro  full-curved  slightly  conical  canulas,  one  fitting  closely 
within  the  other.  The  external  tube  is  usually  provided  with  an  oval  fenes- 
tra  at  its  upper  or  outer  border.  This  fenestra  should  be  so  located  in  the 
tube  that  when  the  inner  one  is  withdrawn,  it  will  communicate  with  that 


SURGERY    OF    THE    MOUTH    AND    THROAT. 

portion  of  the  trachea  that  rests  above  the  point  of  incision.  This  is  to 
enable  the  patient  to  establish  respiration  through  the  mouth  at  times  when 
the  external  tube  opening  is  closed.  That  the  tube  may  be  held  in  proper 
position  a  small  external  oblong  plate  is  provided,  to  which  tapes  may  be 
attached,  passed  around  the  neck  of  the  patient  and  fastened.  That  the 
tube  may  rest  easily  within  the  wound,  it  is  attached  to  this  plate  by  a  loose 


Figure  1588.    Trousseau's  Tracheotomy  Tube,  Figure  1589.    Park's  Tracheotomy  Tube. 

joint  so  adjusted  that  any  slight  tilting  of  the  plate  will  not  tend  to  change 
the  position  of  the  tube.  The  inner  tube  is  held  in  position  by  means  of  a 
hinged  gate.  This  second  tube,  when  in  place,  forms  a  continuous  exter- 
nal connection,  as  it  is  only  when  it  is  removed  that  communication  through 
the  mouth  of  the  patient  is  established.  This  tube  is  manufactured  from 
silver,  brass,  aluminum  and  hard  rubber,  those  of  silver  being  usually  pre- 
ferred. 

They  may  be  procured  in  a  series  of  sizes,  varying  T^  of  an  inch  each. 
The  size  of  the  tube  is  determined  by  the  diameter  of  the  inner  tube  at  its 
narrowest  point.  As  the  sizes  vary  with  different  manufacturers,  the 
diameter  should  be  indicated  in  ordering.  Those  recommended  by  several 
standard  authorities  are  as  follows: 

For  children  under  3  years  old,  a  diameter  of  r3f  of  an  inch. 
From  3  to    6      "         "    "          "          "  T\ 

II  f       it  (  t  i  I        I  t  II  .  .          -  t  ( 

0          9  TV 

it  it      J2  it  «       «  t'     J3  tl 

"       12      "     20          "  "      "  "  "    y{ 

A  tube  YZ  an  inch  in  diameter  has  been  constructed,  but  is  seldom 
employed. 

Park's  Tracheotomy  Tube,  as  illustrated  by  figure  1589,  consists  of  a 
curved  canula  divided  longitudinally.  The  two  tips  unite  in  a  small  acorn- 
shaped  bulb  provided  with  openings  through  which  respiration  may  be 
maintained.  The  halves  of  the  canula  may  be  caused  to  diverge  after  intro- 
duction, by  a  dilating  screw,  until  they  assume  the  desired  size. 

Durham's  Tracheotomy  Tube  is  well  described  by  figure  1590.  The 
body  of  the  tube,  the  part  lying  withifi  the  wound,  is  straight,  the  terminal 
portion  being  sharply  curved.  This  necessitates  an  elastic  or  jointed  can- 
ula, which,  after  passing  through  the  straight  portion  of  the  tube,  will  con- 
form to  the  curve  of  the  intra-tracheal  section.  The  tube  is  provided  with 
a  jointed  pilot,  with  a  conical  tip  by  which  the  tube  is  guided  into  place 
during  introduction.  The  external  neck  plate  is  movable  and  supplied 
with  a  set  screw,  so  that  the  length  of  the  straight  portion  may  be  adjusted 
to  varying  degrees  of  wall  thickness.  This  enables  the  operator  to  adapt 
the  tube  to  special  cases,  and  to  bring  the  distal  end  into  the  axis  of  the 
trachea  each  time  without  producing  undue  pressure  upon  either  the  ante- 
rior or  posterior  wall. 


TREATMENT    OP    STRICTURE. 


687 


One  advantage  claimed  for  this  instrument  is  that  in  the  act  of  degluti- 
tion the  whole  tube  moves  upward,  the  intra-tracheal  portion  retaining  its 
proper  position  and  relation  to  the  surrounding  parts,  instead  of  being 


Figure  1590.    Durham's  Tracheotomy  Tube. 


Figure  1591.    Gendrons'  Dilating  Tracheo 
tomy  Tube. 


crowded  against  and  impinging  upon  the  posterior  wall.  The  instrument  is 
composed  of  a  double  canula,  somewhat  after  the  pattern  of  Trousseau 
previously  described.  As  it  is  difficult  to  clean,  care  must  be  taken  to 
sterilize  it  thoroughly  and  often. 

Gendrons'  Tracheotomy  Tube,  as  traced  in  figure  1591,  consists  of  two 
lateral  plates  similar  to  the  pattern  last  described,  but  provided  in  addition 
with  a  dilating  screw,  by  means  of  which  they  may  be  separated  to  meet  the 


Figure  1592. 


Koenig  s  Tracheotomy  Tube. 


requirements  of  special  cases.  Three  inner  tubes,  small,  medium  and  large, 
accompany  each  instrument.  As  the  lateral  plates  may  be  separated  so  as 
to  admit  the  larger  of  these  tubes,  the  instrument  is  applicable  in  a  great 
variety  of  cases. 


Figure  1593.    Cohen's  Trachea  Tube. 


Figure  1594.    Elsberg's  Tracheotomy  Tube  with 
Pea- Valve. 


Koenig's  Tracheotomy  Tube,  as  shown  by  figure  1592,  consists  of  a 
straight  or  cylindrical  body  terminating  in  a  spiral  elastic  section,  the  latter 
so  constructed  that  it  will  conform  to  any  desired  curve.  This  tube  is  par- 


688 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


ticularly  adapted  for  stenosis  in  the  lower  portion  of  the  trachea.  Usually 
they  are  about  4^  inches  in  length.  They  may  be  purchased  in  three 
sizes,  small,  medium  and  large. 

Cohen's  Tracheotomy  Tube,  as  represented  in  figure  1593,  differs  from 
the  pattern  of  Trousseau  only  in  containing  a  pilot,  by  which  the 
tube  may  more  easily  be  guided  into  position.  This  pilot  is  round-pointed, 
somewhat  conical  in  shape  and  fenestrated. 

Elsberg's  Tracheotomy  Tube,  with  Pea-Valve,  as  explained  in  figure 
1594,  differs  from  the  pattern  of  Trousseau  in  being  constructed  with  a  small 
spherical  valve  so  adjusted  that  during  inspiration  the  valve  is  raised  and 
the  external  opening  through  the  tube  cleared.  During  expiration  the 
valve  closes  this  opening,  so  that  the  air  may  be  forced  out  through  the 
larynx. 


Figure  1595.     Tube  for  Laryngo-Tracheal  Stenosis. 

The  Tube  for  Laryngo-Tracheal  Stenosis,  as  shown  in  figure  1595,  con- 
sists of  a  tube  and  canula  of  the  Durham  pattern,  as  exhibited  in  figure 
1590,  in  connection  with  a  supra-glottic  tube  that  extends  upward  into  the 
larynx.  Figure  "B"  illustrates  the  straight  section  of  the  tube,  the  first  to  be 
introduced.  To  the  distal  end  of  this  tube  the  perpendicular  section  is 
attached.  The  inner  or  tracheal  tube  is  shown  by  figure  "D. "  This,  when 
introduced  forms,  in  connection  with  the  first,  the  apparatus  shown  in  fig- 
ure "A."  The  whole  is  supplied  with  an  inner  canula,  exhibited  by  "C,"  by 
which  the  tube  may  be  cleansed  and  the  external  opening  closed  when  de- 
sired. A  small  attachment,  shown  by  "E,"  forms  a  valve  that  may  be  caused 
to  open  and  close  with  each  respiration. 

Rapid  Tracheotomy,  now  seldom  employed,  may  be  performed  with 
either  of  two  classes  of  instruments.  One,  a  diverging  knife,  that  may  be 
plunged  into  the  trachea,  the  incision  made,  the  wound  dilated  and  the  tube 
inserted;  the  other,  a  form  of  curved  trocar  that  may  be  inserted  into  the 
outer  tracheotomy  tube,  the  whole  plunged  into  the  trachea,  and  the  trocar 
withdrawn  and  replaced  with  an  ordinary  inner  canula.  These  instruments 
are  called 

Tracheotomes. 

Langenbeck's  Tracheotome,  as  exhibited  by  figure  1596,  consists  of  a 
double  knife  curved  upon  the  cutting  edge,  the  two  blades  sharp  pointed 
and  fitting  so  closely  together  that  they  may  be  introduced  as  a  single  blade. 
One  blade  forms  a  portion  of  the  fixed  handle.  That  it  may  dilate  later- 


TREATMENT    OF    STRICTURE. 


ally,  the  second  blade  is  jointed  to  the  first.  It  is  controlled  by  a  lever 
movement  arranged  with  a  spring.  A  screw-stop  is  provided,  by  which  any 
desired  amount  of  dilatation  may  be  maintained.  The  instrument  is  in- 
tended to  act  both  as  a  dilator  and  an  instrument  for  incision. 


Figure  1596.    Langenbeck's  Tracheotome. 

Pitha's  Tracheotome,  as  set  forth  in  figure  1597,  consists  of  two  blades 
so  arranged  that  they  unite  at  their  tips  to  form  a  single  spear-shaped  in- 
strument. The  point  might  be  likened  to  a  flat  trocar  split  by  a  longitudinal 


Figure  1597.    Pitha  s  Tracheotome. 


section,  each  half  curved  at  nearly  a  right  angle  and  extended  in  handle 
form.  It  is  intended  to  force  the  instrument  through  the  tracheal  ring, 
after  which,  by  pressure  on  the  handles,  it  may  be  used  as  a  dilator  for  the 
introduction  of  a  tube. 

Retractors  and  Dilators. 

These  are  employed  to  enlarge  and  preserve  the  patency  of  the  opening, 
either  for  the  insertion  of  a  tube  or  for  examination. 


Figure  1598.    Pilcher's  Retractor. 


Pilcher's  Retractor, 'as  sketched  in  figure  1598,  has  two  prongs  and  is 
mounted  upon  a  straight  shaft  and  handle.  The  blades  are  full  curved  with 
short  prongs,  presenting  a  retracting  surface  about  ^  of  an  inch  in  width. 
These  instruments,  as  usually  constructed,  are  too  large  and  heavy  for 
practical  use. 


Figure  1599.    Trousseau's  Tracheal  Dilator. 


Trousseau's  Tracheal  Dilator,  as  pictured  in  figure  1599,  is  made  up  of 
two  slender  forceps-shaped  blades  curved  on  the  flat.  The  blades  are  well 
rounded  at  their  points  and  of  such  shape  that  they  may  easily  be  passed 
through  the  tracheal  opening.  The  instrument  is  delicate  in  construction 
and  occupies  little  space  within  the  opening. 


44 


690  SURGERY    OF    THE    MOUTH    AND    THROAT. 

Otis'  Tracheal  Retractor,  as  sketched  in  figure  1600,  does  not  differ 
materially  from  the  pattern  of  Trousseau.  Its  principal  advantage  consists 
in  the  substitution  of  two  slender  curved  hooks  for  the  round  blades  in  the 


Figure  1600.    Otis'  Tracheal  Retractor. 

former  pattern.  The  ends  of  the  hooks  are  curved  outward  and  the  instru- 
ment is  self-retaining.  This  overcomes  an  objectionable  feature  in  the 
pattern  of  Trousseau. 


Figure  1601.    Delaborde's  Tracheal  Dilator.  Figure  1602.    Goldenberg's  Trachea  Dila- 

tor. 

Delaborde's  Tracheal  Dilator,  as  demonstrated  in  figure  1601,  consists 
of  three  blades  that  are  caused  to  diverge  from  a  common  center  by  handle 
pressure.  The  two  lateral  sections  are  but  extensions  of  non-crossing 
blades  that  open  or  spread  apart  by  closure  of  the  handles.  To  the  latter 
a  toggle  joint  is  attached,  to  which  the  third  blade  is  secured  in  such  a 
manner  that  it  will  retract  when  the  handles  are  closed.  This  secures 
equal  expansion  of  all  the  blades. 

Goldenberg's  Trachea  Dilator,  as  pictured  in  figure  1602,  has  two  fenes- 
trated  L-shaped  arms  united  by  a  threaded  rod  in  such  a  manner  that  paral- 
lel extension  and  closure  may  be  secured  by  rotating  the  rod  to  the  right  or 
left.  This  furnishes  a  very  simple  instrument  for  securing  lateral  expan- 
sion, for  which  purpose  it  seems  admirably  adapted. 

Intra-Tracheal  Canula  Forceps. 

These  may  be  employed  for  removing  false  membrane  and  other  foreign 
substances  from  the  trachea,  either  directly  through  an  artificial  opening  or 
through  the  tracheotomy  tube. 


Figure  1G03.    Trousseau's  Tracheal  Canula  Forceps. 


TREATMENT    OF    STRICTURE.  691 

Trousseau's  Tracheal  Canula  Forceps,  as  represented  in  figure  1603,  is 
a  delicate  spring  forceps  constructed  upon  the  same  curve  as  an  ordinary 
tracheotomy  tube.  The  jaws  of  the  blades  are  short,  finely  serrated  and 
arranged  to  open  with  only  a  slight  dilating  of  the  blades.  The  opening 
and  closing  are  lateral. 


Figure  1604.    Collins'  Tracheal  Canula  Forceps. 

Collins'  Tracheal  Canula  Forceps,  as  set  forth  in  figure  1604,  are  approxi- 
mately of  the  same  shape  as  the  pattern  last  described  •  excepting  that 
they  have  scissors  handles  and  are  curved  upon  the  edge  so  that  they  open 
antero-posteriorly.  They  are  of  the  alligator-jaw  pattern  and  are  operated 
by  a  compound  lever.  The  edges  are  short  and  finely  serrated. 

Infra-Glottic  Mirror. 

This  is  occasionally  found  necessary  for  inspection  of  the  trachea  follow- 
ing tracheotomy. 


Figure  1605.    Infra-Glottic  Mirror. 

The  Infra-Glottic  Mirror,  shown  by  figure  1605,  consists  of  a  small  mirror, 
usually  with  a  metallic  reflecting  surface,  arranged  for  use  either  within  the 
tracheal  opening  or  upon  the  interior  of  a  fenestrated  tracheotomy  tube. 
It  is  employed  in  connection  with  the  latter  only  for  inspecting  that  portion 
of  the  trachea  which  lies  above  the  point  of  incision. 

Laryngectomy. 

Extirpation  of  the  larynx  may  be  preceded  by  the  insertion  of  a  tracheot- 
omy tube,  or  it  may  or  may  not  involve  tracheotomy  as  a  synchronal  oper- 
ation. To  avoid  a  flow  of  fluid  into  the  trachea  during  this  procedure, 
some  form  of  tamponing  or  closing  the  trachea  is  usually  required.  The 
instruments  necessary  for  this  operation  are  practically  the  same  as  those 
employed  for  tracheotomy  (page  685).  In  addition  to  which  the  oper- 
ator should  supply  himself  with  a 

Soft  rubber  tube  for  maintaining  patency  of  canal,  a 

Stomach  tube  for  introduction  of  food  and  drink,  and  a  trachea  tampon 
canula,  possibly  followed  by  the  insertion  of  an  artificial  larynx. 

Trachea   Tampon  Canula. 

This  consists  of  a  tracheotomy  tube  surrounded  by  an  expanding  bag 
that  may  be  employed  as  a  plug  to  close  the  space  between  the  tube  and 
trachea. 


692 


SURGERY    OF    THE    MOUTH    AND    THROAT. 


Trendelenberg's  Trachea  Tampon  Canula  with  Inhaler,  as  exhibited  in 
figure  1606,  consists  of  a  trachea  canula,  the  distal  end  of  which  is 
covered  for  about  half  an  inch  with  a  rubber  sheath  or  bag  surrounding  the 
tube.  The  space  between  the  sheath  and  canula  is  rendered  air-tight  and 
connected  by  a  slender  tube  with  a  rubber  air-forcing  bulb. 

By  this  means  the  bag  may  be  inflated  and  as  it  is  circular,  and  the  tube 
in  the  center,  it  may  completely  fill  the  space  between  the  canula  and  the 


Figure  1606.     Trendelenberg's  Trachea  Tampon  Canula  with  Inhaler. 

tracheal  walls,  thus  preventing  a  flow  of  blood  below  the  tube.  To  the  tube 
opening  an  inhaling  apparatus  is  attached  when  desired, to  facilitate  the  ad- 
ministration of  an  anesthetic.  Gerster  uses  for  the  same  purpose  a  canula 
with  delicate  steel  springs  arranged  around  the  tracheal  end  of  the  canula, 
over  which  a  rubber  sheath  or  bag  is  securely  fastened.  Dilatation  of  the 
steel  springs  is  produced  by  a  thumb-screw  located  in  the  neck  plate.  By 
action  of  this  screw  the  springs  bulge  outward,  completely  filling  the  intra- 
tracheal  space.  The  apparatus  is  also  provided  with  an  inhaler. 


Figure  1607.    Gussenbauer's  Artificial  Vocal  Apparatus. 

Gussenbauer's  Artificial  Vocal  Apparatus   is  well  shown  in  figure  1607. 
While  this  appliance  can  not  be  termed  a  perfect  success,  patients  who  have 


CLEFT    PALATE.  693 

suffered  a  loss  of  the  trachea  are  able  by  this  device  to  articulate  sufficiently 
to  make  many  of  their  wants  known. 

The  apparatus  consists  of  a  tube  resembling  a  tracheotomy  tube  and 
provided  with  an  upper  intra-tracheal  tube.  A  current  of  air  may  be  di- 
rected upward  through  the  natural  passage  by  a  valve.  A  vibrating  reed  is 
inserted  into  the  angle  formed  by  the  junction  of  these  two  sections  of  the 
tube,  by  which,  if  the  external  opening  of  the  tube  is  closed,  the  current  of 
air  is  thrown  into  vibration  and  thus  utilized  by  tongue,  teeth  and  lips  in 
producing  articulate  sounds. 

One  difficulty  encountered  in  the  way  of  perfect  success  in  the  use  of 
this  instrument  is  the  obstruction  caused  by  the  accumulation  of  secretions, 
together  with  the  fact  that  food  and  drink  easily  find  their  way  into  it.  In 
cases  where  the  entire  epiglottis  is  allowed  to  remain,  it  answers  a  fairly  good 
purpose.  Its  inventor  has,  in  some  cases,  attached  an  artificial  epiglottis 
that  has  been  found  of  utility. 


CLEFT  PALATE. 

The  instruments  particularly  applicable  in  cases  of  cleft  palate  consist 
chiefly  of  special  nipples  for  nursing  children,  obturators  for  non-operative 
cases,  and  appliances  for  staphylorrhaphy,  uranoplasty  and  similar 
procedures. 

Nipples  for  Nursing-  Children. 

One  disadvantage  common  to  this  deformity  is  that  caused  by  the 
escape  of  foods  into  the  nasal  fossae.  This  is  quite  common  among  young 
children,  particularly  infants  requiring  liquid  diet.  Such  food  soon  under- 
goes decomposition,  and  is  at  all  times  difficult  to  dislodge. 


Figure  1608.    Nipple  and  Shield  for  Cases  of  Cleft  Palate. 

The  Cleft  Palate  Nipple,  displayed  in  figure  1608,  consists  of  a  plain 
rubber  nipple  with  a  hood  or  apron  projecting  beyond  the  tip  in  such  a 
manner  as  to  turn  the  flow  of  food  in  a  downward  direction.  This  shield 
is  in  an  inverted  spoon-form  and  in  most  instances  prevents  what  in  many 
of  these  cases  proves  an  annoying  complication. 

Obturators  for  Non-Operative  Cases. 

These  consist  of  bridges  employed  to  span  the  gap  in  the  palate.  They 
may  be  partial  or  complete,  and  of  firm  or  elastic  material.  They  are 
usually  attached  to  the  teeth,  for  which  reason  they  are  not  applicable  in 
early  infancy.  They  serve  to  partially  restore  the  functions  of  the  defec- 
tive parts  by  assisting  in  articulation,  keeping  food  from  entering  the  naso- 
pharynx, etc. 


694 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


Staphylorrhaphy,  Uranoplasty,  Etc. 

These  operations  to  secure  normal  conditions  may  require : 

Anesthesic  appliances,  figures  329  to  351. 

Mouth  gag,  figures  1524  to  1527. 

Tenaculum,  with  long  handle,  for  grasping  flaps  and  edges  of  fissure, 
figures  950  to  952. 

Long  tissue  forceps  for  grasping  delicate  tissues,  figures  947  to  949. 

Scissors,  sometimes  used  instead  of  a  knife,  figures  927  to  929. 

Periosteal  elevator,  used  in  uranoplasty,  for  separating  muco-periosteal 
Haps,  figures  844  to  849. 

Hemostatic  forceps,  figures  647  to  676. 

Cheek  retractor  for  drawing  cheeks  apart. 

Knives  for  excisions. 

Special  curved  needles  and  holder,  figures  953  to  956;  and, 

Silk  or  other  suturing  material,  figures  708  to  728. 

Cheek  Retractors. 

These  consist  of  curved  blades  arranged  to  enclose  the  cheek  at  the 
mouth  angle,  so  that  the  operating  field  may  be  properly  exposed  by  force. 
They  serve  to  increase  the  working  space  and  are  a  necessity  in  many  cases. 


Figure  1609.    Langenbeck's  Cheek  Retractor. 

Langenbeck's  Cheek  Retractor,  as  displayed  by  figure  1609,  consists  of 
two  wire  blades  curved  in  retractor  form,  each  attached  by  a  short  chain  to 
a  band  that  encircles  the  head  posteriorly.  As  the  latter  is  adjustable,  the 
instrument  may  not  only  be  made  self -retaining,  but  may  be  fitted  to  any 
case.  It  possesses  the  advantage  of  supplying  a  fixed  and  uniform  retract- 
ing force. 


Figure  1610.    Leur's  Cheek  Retractor. 

Leur's  Cheek  Retractor,  as  described  by  figure  1610,  is  a  straight  solid 
handle  that  terminates  in  a  semi-circular  concave  blade,  so  shaped  as  to 
spread  and  retract  the  lips  at  the  angles  of  the  mouth.  As  both  the  upper  and 
lower  margins  of  the  instrument  are  alike,  it  may  be  used  upon  either 
side.  Usually  it  is  6  inches  in  length  with  a  width  between  the  upper  and 
lower  blade  terminals  of  about  i  inch. 

Knives. 

Knives  for  paring  the  edges  of  a  fissure  should  be  narrow  and  thin- 
bladed.  Those  usually  preferred  are  in  bistoury  form  with  curved  edges. 


EXTRACTION    OF    TEETH. 


695 


Langenbeck's  Concave  and  Convex  Edge  Knives,  as  detailed  in  figures 
1611  and  1612,  differ  from  each  other  only  in  the  shape  of  the  blade,  one 
cutting  upon  the  outer,  the  other  upon  the  inner  border  of  the  curve. 


Figure  1611.    Langenbeck's  Concave  lidgc  Knife. 


Figure  1G12.     Langenbeck's  Convex-Shaped  Knife. 


Figure  1013.     Langenbeck's  Sickle-Shaped  Knife. 


Langenbeck's  Sickle-Shaped  Knife,  the  form  of  which  is  made  clear  in 
figure  1613,  is  used  by  some  operators  for  dividing  the  muscles  in  staphylor- 
rhaphy. 


EXTRACTION  OF  TEETH. 

This,  though  generally  referred  to  the  dentist,  is  often  required  of  the 
country  practitioner,  who  is  expected  to  relieve  physical  suffering  wherever 
possible. 

Tooth  extraction  requires  little  in  the  way  of  instruments  except 
ordinary  tooth  forceps.  Local  anesthetics  are  often  desirable,  and  special 
instruments  for  the  extraction  of  roots  and  badly  decayed  teeth  may  occa- 
sionally be  required.  For  general  use  in  emergency  cases,  only  a  limited 
number  of  extracting  forceps  are  necessary.  The  writer  recalls  the  early 
years  of  his  father's  practice  when  on  the  frontier  and  compelled  to  "do 
the  tooth-pulling"  for  a  large  section,  a  single  universal  forceps,  such  as  is 
shown  in  figure  1614,  and  a  turnkey  that  was  seldom  used,  embraced  his 
entire  armamentarium  in  this  branch  of  surgery.  Without  advising 
reliance  on  less  than  four  tooth  forceps  from  which  to  select  one  suitable 
for  extracting  a  given  tooth,  we  present  in  this  order  those  generally  pre- 
ferred where  a  less  number  are  employed. 


Figure  1614.    Universal  Forceps. 

The  Universal  Forceps,  as  it  appears  in  figure  1614,  is  constructed  with 
straight  handles,  shanks  slightly  curved  backward  with  jaws  curved  upward 
on  the  flat.  Both  of  the  latter  are  broad,  concave  and  have  transversely 
serrated  inner  surfaces. 

If  the  physician  confines  his  practice  to  a  single  forceps,  this  pattern  is 
usually  selected  as  best  adapted  for  general  work, 


69G 


SURGERY  OF  THE  MOUTH  AND  THROAT. 


The  Universal  Root  Forceps,  as  manifest  in  figure  1615,  differs  from 
the  pattern  previously  described  only  in  the  width  and  length  of  the  jaws. 
The  latter  are  narrow  and  a  trifle  longer  that  the  instrument  may  be 
employed  in  removing  deep-seated  roots.  This  pattern  is  also  available 


Figure  1615.    Universal  Root  Forceps. 


for  extracting  incisors,  and,  because  of  its  narrow  blades,  is  particularly 
applicable  for  pulling  the  teeth  of  children.  Where  the  purchases  of  the 
physician  extend  to  a  second  pair  of  tooth-extracting  forceps,  this  pattern 
is  advised  as  the  second  selection. 


Figure  1616.    Straight  Inci 


rceps. 


The  Incisor  Forceps,  indicated  by  figure  1616,  is  straight  with  con- 
cave serrated  jaws  of  medium  width.  This  pattern  is  probably  the  next 
most  useful,  as  it  is  applicable  for  extracting  the  upper  and  lower  incisors. 
It  may  also  be  used  to  advantage  in  pulling  bicuspids. 


Figure  1617.    Wolverton's  Lower  Molar  Forceps. 

Wolverton's  Lower  Molar  Forceps,  as  represented  by  figure  1617,  may 
be  utilized  upon  either  side.  One  handle,  the  lower,  is  curved  at  its 
extremity  that  it  may  furnish  a  firm  grip.  The  jaws,  as  may  be  seen  by 
consulting  the  figure,  are  of  the  hawk-bill  pattern,  of  proper  shape  for  firm 
insertion  in  the  inter-root  spaces  in  the  lower  molars.  This  pattern  is 
advised  where  purchases  are  limited  to  four  instruments. 


Figure  1618.    Harris'  Upper  Left  Molar  Forceps. 

Harris'  Upper  Right  and  Left  Molar  Forceps,  as  illustrated  by  figures 
1618  and  1619,  differ  in  the  direction  of  the  lateral  curves  of  the  jaws  and 
the  shapes  of  the  beaks  of  each.  As  the  upper  molar  teeth  have  three 
prongs,  two  upon  the  outer  and  one  on  the  inner  side,  a  forceps  if  con- 
structed so  that  the  beaks  will  accurately  fit  the  teeth  must  have  a  straight 


GENERAL    ELECTRICAL    TREATMENT. 


697 


shank  and  beak,  if  it  is  to  be  used  upon  both  sides.  Such  an  instrument 
can  not  be  utilized  to  advantage,  particularly  for  the  superior  molars.  Two 
forceps  are  therefore  advised  for  upper  molar  extraction ;  each,  as  in  the 
patterns  referred  to,  provided  with  a  hawk-bill  beak  on  the  outer,  and  a 
concave  beak  upon  the  inner  surface.  With  these  there  should  be  little 
danger  of  breaking  the  teeth  requiring  extraction. 


Figure  1619.     Harris'  Upper  Right  Molar  Forceps. 


While  there  is  a  diversity  of  opinion,  even  among  dentists  as  to  what 
best  comprises  a  set  of  two,  three  or  more  forceps,  it  is  our  opinion,  after 
many  years  of  experience  in  supplying  and  consulting  with  what  might  be 
called  "country  practitioners,"  that  the  five  forceps  above  mentioned,  and  in 
the  order  named,  are  the  most  desirable  and  practical,  and  embrace  all 
that  are  required  for  general  work. 


GENERAL  ELECTRICAL  TREATMENT. 

This  may  require  electrodes  of  various  forms.  While  a  limited  number 
of  patterns  may  be  obtained  in  the  market,  special  forms  are  frequently  con- 
structed to  meet  the  demands  of  individual  cases. 


Figure  1620.    Tonsil  Electrode. 

The    Tonsil    Electrode,    indicated  in   figure    1620,    consists   of  a   small 
bowl-shaped  cup  attached  to  a  double-curved  cylindrical  shaft. 


TRUAX"-GREENE-CO. 


Figure  1621.     Laryngeal  Sponge  Electrode. 


The  Laryngeal  Sponge  Electrode,  portrayed  in  figure  1621,  consists  of  a 
small  sponge  surrounding  a  metallic  head,  the  latter  forming  the  terminal 
of  an  insulated  shaft  arranged  for  attachment  to  a  universal  handle. 


Figure  1622.     Metallic  Tip  Laryngeal  Electrode.  Figure  1623.     Tongue  Plate  Electrode. 

The  Metallic  Tip  Laryngeal  Electrode,  as  outlined  in  figure  1622,  consists 
of  a  small  metallic  ball  that  forms  the  outer  terminal  of  a  curved  insulated 
shaft.  The  latter  is  arranged  for  attachment  to  a  universal  handle. 

The  Tongue  Plate  Electrode,  as  sketched  in  figure  1623,  consists  of  a  thin, 
ovoid,  metallic  disc  attached  to  an  insulated  shaft  and  arranged  for  connec- 
tion with  a  universal  handle. 


CHAPTER  XXVI. 


SURGERY  OF  THE  ESOPHAGUS. 

The  instruments  required  in  surgery  of  the  esophageal  canal  may  be 
divided  into  those  for  examination,  treatment  of  strictures,  removal  of  for- 
eign bodies  and  permanent  tubage. 

EXAMINATIONS. 

The  instruments  applicable  for  examinations  of  the  esophagus  are  lim- 
ited to  the  esophagoscope,  bougies  and  sounds. 

Esophagoscopes. 

These  consist  of  dilating  specula  and  mirrors  or  a  combination  of  mir- 
rors and  lenses  so  arranged  as  to  afford  ocular  examination  of  the  esophagus. 


Figure  1624.    Dilating  Mirror  Speculum. 

The  Dilating  Mirror  Speculum,  as  may  be  seen  by  consulting  figure  1624, 
is  made  up  of  two  parallel  wires,  six  or  more  inches  in  length,  joined  to- 
gether by  four  small  hinged  rings  in  such  a  manner  that  the  speculum  may 
be  folded  flat  for  introduction.  The  wires  forming  the  blades  rest,  one  ante- 
riorly, the  other  posteriorly,  against  the  canal  walls.  The  posterior  blade 
is  fixed  to  a  handle  that  projects  at  right  angles  with  the  blades.  Its  mate 
is  hinged  and  controlled  by  a  lever  operated  by  a  thumb-piece  that  slides 
along  the  shank  of  the  instrument.  A  mirror  is  attached  to  the  upright 
border  of  the  speculum  portion  and  inclined  at  an  angle  of  45°,  by  which 
light  may  be  reflected  into  the  esophagus,  and  the  visual  rays  returned  by 
the  aid  of  the  same  mirror. 


EXAMINATIONS. 


699 


Bougies,  Sounds  and  Probangs. 

These  differ  from  tubes  in  possessing  greater  rigidity.  Usually  they 
have  sufficient  stiffness  to  impart  a  delicate  sense  of  touch,  so  that  the  oper- 
ator may  be  able  to  determine  certain  conditions,  even  if  the  parts  under 
inspection  are  deep-seated.  They  are  useful  in  determining  the  permeabil- 
ity of  the  canal,  the  existence  and  extent  of  obstructions,  and  often  the 
presence  and  location  of  foreign  bodies. 


Figure  1625.    Olive  Tip  Bougie. 

The  Olive  Tip  Bougie,  the  distal  end  of  which  is  sketched  in  figure  1625, 
is  of  elastic  web  and  similar  in  manufacture  to  those  for  use  in  the  urethra, 
from  which  they  differ  only  in  size  and  length.  They  may  be  obtained  of 
various  sizes,  the  usual  length  being  about  28  inches. 


Figure  1626.    Cylindrical  Bougie. 

The  Cylindrical  Bougie,  delineated  in  figure  1626,  does  not  differ  from 
the  pattern  last  described,  excepting  in  the  shape  of  the  point.  As  they  are 
not  as  well  adapted  for  penetrating  or  dilating  cicatricial  contractions  or  fol- 
lowing a  deflected  canal,  they  are  seldom  employed. 


Figure  1627.    Bulbous  Sounds. 

The  Bulbous  Sounds,  traced  in  figure  1627,  comprise  a  series  of  olive- 
shaped  bulbs  attached  to  an  elastic  whalebone  shaft.  The  latter  is  pro- 
vided with  a  metallic  handle,  usually  hollow,  that  it  maybe  used  as  a  cham- 
ber for  storage  of  the  extra  bulbs  when  not  in  use.  The  length  of  the  shaft 
is  usually  about  17  inches,  while  the  length  of  the  complete  instrument  is 
22  inches.  As  shown  in  the  illustration,  the  bulbs  are  of  various  forms  and 
are  attached  to  the  shaft  by  means  of  a  screw  joint.  As  whalebone  is  a 
tenacious  and  elastic  material,  this  combination  presents  one  of  the  most 
useful  and  serviceable  instruments  of  its  class. 


Figure  1628.    Turck's  Elastic  Bougie. 

Turck's  Elastic  Bougie,  as  shown  in  figure  1628,  consists  of  a  spiral  cable 
enclosed  within  a  rubber  hose,  its  gastric  end  provided  with  a  series  of  olive- 
shaped  bulbs  attached  by  screw  mechanism.  It  is  evident  that  this  instru- 
ment is  much  safer  in  the  hands  of  the  average  practitioner  than  the  more 
rigid  pattern  previously  described.  With  the  latter,  particularly  in  cancer- 
ous cases,  a  perforation  might  easily  be  made.  The  soft  flexible  spiral 
cable  here  shown  readily  conforms  to  any  inequalities  and  announces 
obstruction  when  encountered. 


700  SURGERY    OF    THE    ESOPHAGUS. 

TREATMENT  OF  STRICTURE, 

This  may  be  treated  by  dilators  and  esophagotomes. 

Dilators. 

Dilatation  may  be  attempted  with  bougies,  sounds  or  expanding  dilators. 
The  two  former  have  been  described  by  figures  1625  to  1628. 


Figure  1629.     Pinkerton's  Esophageal  Dilator. 

Pinkerton's  Esophageal  Dilator,  as  represented  in  figure  1629,  consists 
of  a  spiral  elastic  shaft  terminating  in  a  short  rigid  section,  provided  with 
expanding  mechanism.  The  principle  is  similar  to  that  employed  in  the 
manufacture  of  those  urethral  instruments  in  which  a  short  bar  placed 
longitudinally  between  the  blades  is  caused  to  gradually  assume  an  angular 
or  cross  position,  thus  forcing  the  blades  apart.  The  tip  of  the  instrument 
is  slender  and  bulb-pointed.  Its  entire  length  is  about  20  inches. 

Esophagotomes. 

Instruments  employed  for  incising  cicatricial  bands  should  be  used  with 
great  caution,  as  the  operation  is  attended,  even  in  the  hands  of  experts, 
with  great  danger.     In  case  of  stricture  it  is,  as  a  rule,  desired  to  cut 
'  through  the  mucous  membrane  only. 


Figure  1630.    Sand's  Esophagotome. 

Sand's  Esophagotome,  as  traced  in  figure  1630,  consists  of  a  slender 
shaft  terminating  in  a  bulb,  the  latter  slotted  and  provided  with  a  concealed 
blade  that  may  be  projected  by  mechanism  contained  within  the  handle. 
The  latter  is  supplied  with  a  screw  device  by  which  an  inner  rod  that  con- 
trols the  knife  blade  is  manipulated.  A  dial  or  marker  measures  the 
amount  of  blade  protrusion. 


REMOVAL  OF  FOREIGN  BODIES. 

The  instruments  that  may  be  employed  in  the  removal  of  foreign  bodies 
from  the  esophagus  may  be  classified  as  those  for  examination  and  those 
for  extraction. 

Diagnostic  instruments  will  be  required  only  in  special  or  obscure  cases. 
Those  most  commonly  used  are  esophagoscopes,  sounds,  bougies  and 
resonators.  The  first  three  will  be  found  described  in  preceding  por- 
tions of  this  chapter. 

Esophageal  Resonators. 

These  usually  consist  of  a  metallic  tube  attached  to  a  suitable  chamber 
and  ear-piece,  the  whole  so  arranged  that  any  metallic  "clicks,"  even  if 
slight,  caused  by  the  contact  of  two  metal  surfaces  may  be  distinguished. 


REMOVAL    OF    FOREIGN    BODIES. 


701 


Duplay's  Resonator,  as  exhibited  by  figure  1631,  consists  of  an  oval  or 
bulbous  tip,  a  slender  tube  of  sufficient  length  to  reach  the  lower  portion  of 
the  esophagus,  a  cylindrical  sounding  chamber,  an  elastic  tube  and  suit- 
able ear  piece,  the  whole  arranged  so  that  any  sounds  caused  by  striking  a 
metallic  substance  with  the  tip  may  be  conveyed  directly  to  the  ear.  With 


Figure  1631.    Duplay's  Esophageal  Resonator. 

this  instrument  metallic  bodies  in  any  portion  of  the  esophagus  can  be 
located,  provided  they  are  not  encysted.  That  part  of  the  tube  which  passes 
between  the  teeth  should  be  covered  with  soft  rubber,  that  the  striking 
of  the  instrument  against  them  may  not  be  mistaken  for  metallic  contact. 

Extracting  Instruments. 

These,  according  to  Poulet  (Burnett),  may  be  divided  into  prehensors, 
conductors  and  dilators. 

Instruments  Used  as  Prehensors. 

Prehensor  instruments  are  those  with  which  the  foreign  body  is  grasped 
anteriorly  and  drawn  out.  They  consist  of  forceps  of  various  forms,  open- 
ing antero-posteriorly,  laterally  and  in  an  infra-supra  direction. 


Figure  1632.     Roe's-Bond's  Esophageal  Forceps. 

Roe's-Bond's  Esophageal  Forceps,  as  displayed  in  figure  1632,  consists  of 
a  forceps  slightly  curved  upon  the  flat  throughout  its  entire  length  of  blade. 
The  pivot  is  located  near  the  handle,  and  the  blades  so  shaped  as  to  present  a 
serrated  jaw  fully  6  inches  in  length;  in  other  words,  the  entire  length 
of  the  blades  from  the  pivot  to  the  distal  end  are  serrated  to  form  jaws. 
These  inner  surfaces  are  in  the  form  of  central  ridges,  the  blades 
being  beveled  upon  either  side,  thus  presenting  narrow  grasping  surfaces. 
The  forceps  should  be  introduced  with  the  blades  spread  as  far  as 
possible  while  being  passed  down  the  esophagus,  when,  if  an  article 
be  engaged  at  any  point  along  the  line  of  the  serration,  it  may  be  held. 
The  entire  length  is  about  1  2  inches.  This  instrument  also  permits  long  slen- 
der articles  to  rest  nearly  parallel  with  the  forceps  blades,  thus  facilitating 
their  withdrawal. 

Charrieres'  Esophageal  Forceps,  as  set  forth  in  figure  1633,  are  about 
14  inches  in  length,  and  present  a  long  slender  curve  terminating  in 
alligator-shaped  jaws,  the  latter  operated  by  a  compound  lever.  As  the  jaws 
are  provided  with  four  sharp  backward-pointed  teeth,  the  instrument  will 


^-LiEi£ir 


702  SURGERY    OF    THE    ESOPHAGUS. 

retain  a  firm  grasp  upon  any  article  contained  in  its  bite.  It  has  the  advan- 
tage of  opening  widely  without  placing  the  upper  portion  of  the  esophagus 
on  a  stretch. 


Figure  1633.    Charriere's  Esophageal  Forceps. 


The  Spiral  Esophageal  Forceps,  as  shown  in  figure  1634,  consist  of  an 
elastic  tubular  forceps  formed  by  two  spiral  tubes,  one  furnishing  the  body 
or  cylinder  of  the  instrument,  the  other  the  shaft  or  active  portion.  Two 
fenestrated,  sharply-serrated  blades  are  attached  to  the  shaft  and  so  ad- 
justed at  the  distal  end  of  the  instrument  that  when  the  shaft  is  pushed  for- 

n 
"a 


iTT'r  ff  f:frfr:* 


Figure  1634.    Spiral  Esophageal  Forceps. 

ward  by  pressure  upon  the  thumb-ring,  the  blades  are  caused  to  diverge  or 
separate.  By  releasing  the  pressure,  the  blades  will  retract  and  close  by 
the  action  of  the  spring,  and  thus  grasp  any  article  contained  within  their 
bite.  After  securing  an  object,  if  its  forced  withdrawal  be  difficult,  traction 
should  be  made  upon  the  thumb-ring  only,  as  this  increases  the  pressure  or 
biting  force  of  the  blades.  The  entire  length  of  the  instrument  is  about  15 
inches. 

Conductors. 

Conductors  for  the  removal  of  foreign  bodies  comprise  such  instruments 
as  are  intended  to  be  passed  beyond  the  substance,  and  so  shaped  as  to  draw 
it  out  when  the  instrument  is  retracted.  Among  these  may  be  mentioned 
hooks,  buckets,  and  the  various  forms  of  coin  and  bone  catchers. 


Figure  1635.    Bucket  Coin  Catcher. 

The  Bucket  Coin  Catcher,  a  likeness  of  which  may  be  seen  in  figure 
1635,  is  a  small  conical  bucket  with  flattened  sides.  A  shaft  passes  through 
the  long  diameter,  to  which  is  firmly  attached  a  whalebone  rod  about  16  or 
1 8  inches  in  length.  This  instrument  is  particularly  adapted  for  removing 
coins  and  small  articles  from  the  esophagus.  The  shape  of  the  instru- 
ment is  such  that  it  will  readily  pass  by  most  forms  of  foreign  bodies.  If 
the  foreign  substance  be  of  considerable  size,  it  will  naturally  force  the  rod 
to  the  opposite  side  of  the  esophageal  wall.  This  will  cause  a  tilting  of 
the  bucket  so  that  it  will  present  an  open  surface  to  the  side  on  which  the 
foreign  body  is  located,  thus  assisting  in  engaging  and  removing  the  object. 
The  end  opposite  to  the  bucket  is  supplied  with  a  small  sponge  used  for  push- 
ing articles  into  the  stomach  that  can  not  be  extracted  with  the  bucket. 

0    BFJHJJI^J 


REMOVAL    OF    FOREIGN    BODIES. 


703 


Graefe's  Coin  Catcher,  as  shown  in  figure  1636,  consists  of  an  elastic 
stem  to  the  distal  end  of  which  two  rings  are  attached,  each  having  its  long 
axis  extending  backward  at  an  angle  of  about  15°.  These  rings  are  united 
at  their  outer  margins,  at  which  point  the  shaft  is  attached.  The  beveled 


Figure  1636.    Graefe's  Coin  Catcher. 


face  presented  by  this  instrument  enables  the  operator  to  slide  it  past  many 
foreign  bodies.  Owing  to  the  peculiar  shape  of  the  instrument  when  re- 
tracted, each  ring  or  side  is  in  the  form  of  a  bucket,  and  with  it  many  sub- 
stances may  be  dislodged  and  extracted. 


Figure  1637.    Roe's  Elastic  Spiral  Extractor. 

Roe's  Elastic  Spiral  Extractor,  as  defined  in  figure  1637,  consists  of  an  elas- 
tic metallic  tube,  in  the  center  of  which  a  copper  rod  may  be  caused  to  move 
backward  or  forward  by  the  action  of  the  thumb-ring  that  forms  a  portion 
of  the  handle  of  the  instrument.  The  distal  point  of  the  instrument  con- 
sists of  a  spoon-shaped  curette  hinged  in  such  a  manner  that,  by  means  of  the 
rod  previously  referred  to,  it  may  be  flexed  until  it  rests  at  a  right  angle 
with  the  shaft  of  the  instrument.  The  extractor  may  be  introduced  while 
the  cup-shaped  portion  is  extended.  If  passed  below  the  foreign  body,  by 
flexing  the  tip  and  withdrawing  the  instrument,  the  offending  substance 
may  often  be  removed. 

Dilators. 

These  serve  to  enlarge  the  canal  and  either  act  as  a  means  of  forcing  the 
foreign  body  into  the  stomach  or  of  dislodging  and  extracting  the  same  while 
being  withdrawn.  They  consist  of  some  form  of  probang  generally  manu- 
factured from  bristles. 


Figure  1638.    Gross'  Bristle  Probang. 

Gross'  Bristle  Probang  illustrates  the  ordinary  form  of  probang  used  for 
the  removal  of  foreign  bodies.  As  shown  in  figure  1638,  it  consists  of  a  web 
catheter-like  tube,  around  the  outer  border  of  the  distal  end  of  which  a  row  of 
bristles  is  firmly  secured.  A  rod  passes  through  the  tube  and  circle  of  bristles, 
the  terminal  ends  of  the  bristles  being  tied  around  the  rod  and  having  their 
tips  covered  with  a  small  piece  of  sponge  or  a  bulbous  tip.  The  proximal 


704  SURGERY    OF    THE    ESOPHAGUS. 

end  of  the  rod  is  attached  to  a  thumb-ring,  while  a  spool-shaped  cylinder  is 
secured  to  the  proximal  end  of  the  shaft.  By  retracting  the  central  rod  the 
bristles  are  caused  to  double  or  bulge  outward,  forming  an  elastic  ring  com- 
posed of  minute  fibers  that  are  of  sufficient  strength  not  only  to  dislodge 
almost  any  foreign  substance  with  which  they  may  be  brought  in  contact, 
but  to  remove  it.  Before  introduction  the  sponge  should  be  moistened,  the 
instrument  passed  below  the  point  of  supposed  lodgment,  the  ring  retracted 
and  the  row  of  bristles  expanded,  in  which  condition  the  instrument  should 
be  withdrawn. 


Figure  1639.    Sponge  Probang. 


The  Sponge  Probang,  as  illustrated  in  figure  1639,  consists  of  an  elastic 
whalebone  rod,  to  which  may  be  attached  sponges  of  various  sizes.  These 
may  be  selected  according  to  the  nature  of  the  case  in  hand.  They  may  be 
introduced  with  the  sponge  either  dry  or  wet.  If  moist,  they  can  be  em- 
ployed only  to  push  or  force  the  offending  substance  along  the  canal  until  it 
makes  its  exit  into  the  stomach.  When  used  for  extraction,  the  sponge  may 
be  compressed  in  the  same  manner  as  that  described  under  the  heading  of 
"Dilators"  in  the  chapter  devoted  to  "Gynecological  Surgery."  Some 
authors  advise  that  a  moist  sponge  be  compressed  by  winding  with  narrow 
ribbon,  the  latter  to  be  so  attached  that  a  protruding  end  may  be  drawn 
upon,  the  whole  covering  of  the  sponge  removed  and  the  latter  released 
while  in  situ. 

Permanent  Tubage. 

This  is  sometimes  advised  as  a  means  of  avoiding  a  gastrostomy  or 
esophagostomy.  At  best  it  is  only  a  palliative  measure  to  prolong  life  in 
cases  of  cancerous  stricture.  It  avoids  the  discomforts  and  dangers  of  a 
major  operation,  and  in  many  cases  secures  practically  as  good  results.  For- 
merly, tubes  extending  the  full  length  of  the  esophagus  were  employed. 
Those  now  advised  are  short,  usually  about  6  inches  in  length. 


Figure  1640.    Symond's  Tube  for  Permanent  Tubage. 

Symond's  Tube,  as  drawn  in  figure  1640,  consists  of  a  funnel-shaped- 
elastic  cylinder,  usually  about  6  inches  in  length.  It  should  be  long  enough 
to  include  and  project  some  distance  below  the  constricted  area.  To  the 
end  of  the  funnel  a  loop  of  thread  or  silk  cord  is  attached,  one  end  of  which 
should  be  permanently  retained  by  attachment  to  the  teeth  or  ear  of  the 
patient.  The  instrument  may  be  best  introduced  by  a  director,  as  shown 
in  the  illustration.  It  consists  of  a  slender  shaft,  the  distal  end  of  which 
terminates  in  a  cylinder  whose  upper  face  is  cut  obliquely  that  the  instru- 
ment may  be  withdrawn  without  injuring  the  soft  tissues.  Two  lateral 
slots  are  used  to  enlarge  the  loop  of  thread,  as  set  forth  in  the  figure. 


CHAPTER  XXVII. 


SURGERY  OF  THE  STOMACH. 

The  various  appliances  that  may  be  utilized  in  this  branch  of  surgery 
consist  of  instruments  for  examinations,  washing  or  lavage,  motor  insuffi- 
ciency, gastritis,general  electrical  treatment  and  forcible  removal  of  contents. 

EXAMINATIONS. 

The  instruments  used  in  examination  of  the  stomach  may  be  classified 
as  those  for  percussion  and  auscultation,  removal  of  stomach  contents,  elec- 
tric trans-illumination,  gastroscopes  for  ocular  inspection,  gyromele  for 
determining  location,  size  and  condition,  appliances  for  sounding,  such  as 
bougies,  tubes,  etc.,  intra-gastric  bag  reservoirs  to  determine  capacity, 
location,  etc. 

Percussion  and  Auscultation. 

Percussion  and  Auscultation  of  the  stomach  require  no  other  appliances 
than  those  described  in  the  chapter  devoted  to  "Mechanical  Aids  in  Diag- 
nosis," to  which  the  reader  is  referred. 

Removal  of  Stomach  Contents  and  Diagnosis. 

Removal  of  Stomach  Contents  for  examination  may  be  secured  by  means 
of  tubes,  buckets,  sponges,  pumps,  etc. 

Stomach  Tubes. 

These,  as  their  name  implies,  consist  of  elastic  tubes  28  or  more  inches 
in  length,  provided  with  inlet  openings  at  the  gastric  end,  and  arranged 
for  the  outward  passage  of  the  stomach  contents  by  suction,  expression  or 
syphonage.  They  may  be  either  single  or  double-channeled,  and  with  or 
without  forcing  bulbs.  Generally  they  are  from  30  to  60  inches  in  length, 
of  soft  rubber  or  elastic  web,  the  former  generally  preferred.  They  are 
employed  to  determine  the  functional  condition  of  the  stomach  and  are 
especially  used  to  irrigate,  introduce  food,  medicaments,  or  instruments  to 
determine  location,  area  and  borders,  and  as  a  means  of  inflation  or  evacua- 
tion. In  texture  they  should  be  soft  and  elastic,  with  just  enough  rigidity 
not  to  buckle  or  curl  on  introduction.  In  making  selections  the  physician 
should  attach  much  importance  to  the  location,  size  and  nature  of  the 
gastric  openings.  These  may  be  located  in  the  end  or  along  the  sides 
of  the  tube.  When  used  for  lavage,  end  openings  with  small  lateral 
perforations  are  all  that  is  necessary.  Two  openings  are  essential,  other- 
wise when  evacuating  the  stomach  contents  the  mucous  lining  may  be 
drawn  into  and  occlude  the  tube.  In  such  cases  a  sudden  movement  of  the 
tube  might,  and  probably  would  cause  laceration  of  the  tissues.  As  the 
instrument  would  in  such  a  case  act  as  a  cupper,  operators  generally  advise 
that  the  tube  be  constructed  with  one  side  opening  near  the  point,  the 
diameter  of  the  opening  being  equal  to  the  lumen  of  the  tube,  and  this  to 
be  supplemented  by  additional  openings  further  from  the  point.  Tubes 
of  faulty  design  are  arranged  with  a  second  large  opening.  As  this  serves 
to  weaken  the  tube,  it  is  a  disadvantage ;  furthermore,  if  the  openings  be 
«ach  as  large  or  nearly  as  large  as  the  lumen,  the  stomach  contents  could 

«  705 


706 


SURGERY    OF    THE    STOMACH. 


not  be  evacuated  below  the  second  or  upper  opening.  The  additional 
openings,  therefore,  should  be  of  limited  diameter,  and  where  several  are 
made  they  should  not  aggregate  as  much  as  the  large  or  lower  one  pre- 
viously referred  to.  That  these  tubes  may  be  easily  cleansed  they  should 
be  constructed  with  a  solid  end  on  the  principle  of  the  catheters,  exhibited 
by  figure  1265.  The  edges  of  the  openings  should  be  soft  with  smooth 
margins,  and  the  surface  of  the  catheter  should  be  of  smooth  molded 
rubber.  All  should  be  warmed  in  water  and  tested  to  see  that  the  lumen 
is  not  obstructed  before  use. 


Ewald's  Stomach  Tube,  as  shown  in  figure  1641,  is  made  from  soft 
rubber,  with  firm  walls  and  an  opening  in  the  end  of  the  tube.  Side 
openings,  usually  from  9  to  12  in  number,  are  located  within  one  or  two 
inches  of  the  distal  end  of  the  tube. 


Figure  1642.    Van  Valzah  and  Nesbit's  Stomach  Tube. 

Van  Valzah  and  Nesbit's  Stomach  Tube,  as  pictured  in  figure  1642, 
differs  from  the  pattern  of  Ewald  in  that  the  tube  opening  is  at  the  side 
instead  of  in  the  end  of  the  tube.  This  opening  should  have  about  the 
same  lumen  as  that  of  the  tube.  A  second  opening  of  much  smaller  size 
is  located  upon  the  side  opposite  to  the  large  one  and  on  a  level  with  the 
upper  border  of  the  latter.  This  second  opening  lessens  the  chances  of 
complete  obstruction  without  materially  weakening  the  tube.  When  prop- 
erly constructed,  all  that  portion  of  the  tube  external  to  the  opening  is  filled 
with  rubber,  thus  furnishing  not  only  a  solid  end,  but  one  that  can  not 
serve  as  a  hiding-place  for  disease  germs. 


Figure  1643.    Soft  Rubber  Stomach  Tube  with 
Funnel. 


Figure  1&44.    Soft  Rubber  Stomach  Tube  with 
Funnel  and  Exhaust  Bulb. 


The  Two  Stomach  Tubes,  shown  by  figures  1643  and  1644,  differ  from 
each  other  in  that  one  is  supplied  with  a  small  exhaust  bulb  by  means  of 
which  a  syphon  force  may  be  started.  Both  are  supplied  with  funnels, 
which  with  the  tube  form  a  single  piece,  and  by  means  of  which  fluids  may 
be  directed  into  the  stomach.  Usually  they  are  about  60  inches  in  length 
and  vary  in  size  from  18  to  23,  American  scale. 


EXAMINATIONS. 


707 


Turck's  Double  Stomach  Tube,  the  form  of  which  is  made  clear  in 
figure  1645,  consists  of  two  soft  rubber  tubes,  resting  side  by  side,  the 
interstices  between  them  filled  with  soft  rubber  in  such  a  manner  that  the 
two  present  a  flattened  or  tape-like  form.  Experience  has  proven  that  a 
tube  of  this  shape  may  be  readily  swallowed  by  the  patient  and  that  but 


Figure  1645.    Turck's  Double  Stomach  Tube. 


Figure  1646. 


Einhorn's  Stomach 
Bucket. 


little  effort  is  required  for  its  introduction.  As  will  be  seen  in  the  illustra- 
tion, the  tubes  at  their  proximal  ends  are  not  united,  and  for  this  reason 
they  may  be  easily  attached  to  a  reservoir  and  escape  pipe.  The  smaller, 
or  injection  tube,  is  about  4  inches  shorter  than  its  mate,  reaching  to  the 
cardiac  opening  of  the  stomach  only.  The  larger  and  longer  one  is 
employed  for  the  return  flow,  and  is  provided  with  a  double  opening.  It 
may  be  used  with  or  without  an  evacuating  bulb. 

Turck's  Stomach  Evacuating  Apparatus,  as  disclosed  in  figure  1647, 
consists  of  a  vacuum  bottle,  to  which  is  attached  a  stomach  tube  and  an 
exhaust  bulb.  The  bottle  is  closed  with  a  double  perforated  rubber  stopper 
that  admits  two  curved  glass  tubes.  To  one  a  soft  rubber  stomach 
tube  is  attached  by  a  rubber  hose ;  to  the  other  tube  is  attached  an  exhaust 


Figure  1647.    Turck's  Stomach  Evacuating 
Apparatus. 


Figure  1648.    Turck's  Intra-Gastric  Reagent 
Capsule. 


bulb,  with  which  a  vacuum  may  be  created  in  the  bottle.  This  appliance, 
though  simple  in  form,  is  an  admirable  contrivance  for  securing  the 
stomach  contents  when  desired  for  examination.  It  also  has  a  particular 
application  for  feeding  patients.  Liquid  food  may  be  placed  in  the  bottle, 
the  latter  connected  with  the  stomach  tube  and  the  contents  readily  forced 
into  the  stomach. 

Stomach    Buckets  and  Capsules. 

These  consist  of  small  capsule-shaped  tubes,  designed  for  direct  intro- 
duction into  the  stomach,  which,  after  being  filled  with  liquid  stomach  con- 
tents, may  be  withdrawn  by  a  previously  attached  cord. 

Einhorn's  Stomach  Bucket,  as    outlined   in  figure   1646,  consists  of  an 


708 


SURGERY    OF    THE    STOMACH. 


intra-gastric  silver  capsule  constructed  with  an  inner  bail,  to  which  a  cord 
may  be  attached.  When  thus  arranged,  the  apparatus  may  be  swallowed 
as  easily  as  a  capsule  and  withdrawn  by  means  of  the  attached  cord.  For- 
merly they  were  constructed  with  a  trap  that  closed  with  a  gentle  pulling 
of  the  cord.  As  it  is  evident  that  the  bucket  when  rilled  could  not  add  to 
its  contents  in  its  passage  through  the  esophagus,  the  trap  is  an  unneces- 
sary adjunct.  In  the  absence  of  this,  a  sponge  similarly  attached  to  a  cord 
may  be  used  instead.  It  should  first  be  immersed  in  dilute  hydrochloric 
acid  to  remove  any  lime  deposits.  It  may  then  be  compressed,  dried  and 
swallowed,  to  be  withdrawn  when  saturated  with  the  gastric  fluid. 

Turck's  Intra-Gastric  Reagent  Capsule,  as  shown  in  figure  1648,  con- 
sists of  a  small  piece  of  rubber  hose  about  an  inch  in  length,  so  arranged  as 
to  firmly  hold  three  test  papers.  The  latter  consist  of  litmus,  congo  red, 
and  diamethyl-amidoazo-benzol  paper  respectively,  each  held  in  place  by 
lateral  slits  in  the  rubber  hose.  '  To  the  latter  a  silk  cord  is  attached,  by 
which  it  may  be  withdrawn  from  the  stomach  after  the  papers  are  saturated. 
One  or  two  shot  are  usually  attached  to  the  lower  end  of  the  hose  that  the 
whole  may  sink  to  the  lower  border  of  the  stomach.  The  whole  is  included 
in  a  large  capsule,  that  it  may  be  easily  swallowed.  With  this  combination 
the  chemical  nature  of  the  stomach  contents  may  be  accurately  determined. 

Electric  Trans-Illumination. 

This  may  be  secured  by  means  of  electrodes  introduced  into  the  stomach 
through  the  esophagus.  They  are  employed  to  locate  the  stomach  curva- 
tures and  the  pylorus,  determine  their  position  and  size,  the  existence  of 
tumors,  to  diagnose  some  forms  of  disease  and  exclude  others. 


Figure  1649.    Ewald-Einhorn's  Stomach  Lamp. 

Ewald's  Modification  of  Einhorn's  Stomach  Lamp,  as  traced  in  figure 
1649,  consists  of  an  electric  light  enclosed  in  a  glass  capsule  and  attached 
to  a  stomach  tube.  Through  the  latter,  insulated  wires  may  connect  the 
lamp  with  a  storage  or  other  battery.  As  the  glass  globe  enclosing  the 
electric  light  is  no  larger  in  diameter  than  the  stomach  tube,  the  physician 
need  encounter  no  difficulty  in  its  introduction. 

Gastroscopes. 

These  comprise  a  system  of  lenses  with  a  mirror  and  electric  light,  the 
whole  mounted  in  a  tube  from  27  to  28  inches  in  length,  and  arranged  for 
ocular  inspection  of  the  stomach. 

The  Electric  Gastroscope,  exhibited  in  figure  1650,  consists  of  a  straight 
tubular  instrument  about  12  millimeters  in  diameter  and  68  centimeters  in 
length.  It(  comprises  four  systems  of  tubes,  the  whole  terminating  in  a 
bulbous  proximal  end,  in  which  are  arranged  the  different  conduits.  The 
inner  tube  contains  the  optical  apparatus,  the  ocular  being  located  at  the 
proximal  end.  The  distal  end  is  supplied  with  an  electric  light,  a  prism, 
and  a  reflecting  mirror  on  the  principle  of  the  cystoscope  described  on 


EXAMINATIONS. 


page  530.  By  means  of  a  double  tube  and  proper  connections,  a  stream  of 
water  is  caused  to  pass  throughout  the  length  of  the  instrument,  encir- 
cling the  lamp  in  its  passage.  This  serves  to  prevent  excessive  heating  of 
the  tabes  by  contact  with  the  incandescent  lamp.  A  third  canal  contains 


Figure  1650.    Electric  Gastroscope. 

the  insulated  wires;  a  fourth  tube  is  employed  to  introduce  air  or  water 
by  means  of  which  the  stomach  walls  are  distended.  With  this  instrument 
it  is  possible  without  moving  the  instrument  to  inspect  an  area  5  centime- 
ters in  diameter  at  a  distance  of  5  centimeters  from  the  lower  lens. 

The  Gyromele. 

The  Gyromele  consists  of  a  revolving  sound  or  massage  instrument 
employed  to  determine  the  location,  size  and  condition  of  the  stomach  for 
purposes  of  cleansing  and  for  exciting  normal  muscular  action. 


Figure  1651.    Turck's  Gyromele. 


Turck's  Gyromele,  as  may  be  seen  by  referring  to  figure  1651,  consists 
of  a  flexible  cable,  to  the  distal  end  of  which  is  attached  an  apparatus  that  in 
its  mechanism  is  not  unlike  the  rotating  egg-beater  common  in  almost 
every  household.  That  the  cable  may  be  revolved  without  injury  to  the 
mucous  surfaces,  it  is  enclosed  within  a  soft  rubber  tube.  The  gastric  end 
of  the  cable  is  arranged  for  attachment  to  various  forms  of  instruments. 
That  most  common  in  use  is  a  spiral  spring  covered  with  sponge.  This  is 
used  for  diagnostic  and  therapeutic  purposes.  When  in  use,  it  may  be 
caused  to  traverse  the  entire  circumference  of  the  stomach,  including  the 
greater  and  lesser  curvatures.  With  it  the  pylorus  may  be  located,  its  bor- 
ders determined,  and  in  many  cases  the  instrument  may  be  passed  into  the 
duodenum. 


710  SURGERY    OF    THE    STOMACH. 

Vibrations  of  the  revolving  sponge  may  be  transmitted  through  the  ab- 
dominal wall,  during  which  the  latter  may  be  palpated  and  the  gastric  area 
thus  outlined  on  the  outer  wall  with  a  dermal  pencil.  Cables  of  varying 
flexibility  may  be  employed  to  show  different  degrees  of  distensibility. 
The  sponge  attachment  may  be  also  used  for  cleansing  the  stomach  walls, 
for  which  purpose  it  forms  an  admirable  adjunct  to  treatment  by  lavage. 
The  sponge  may  be  used  to  remove,  by  rotary  contact,  material  adhering 
to  the  stomach  wall.  This  may  include  mucus,  food  detritus,  leucocytes, 
gland-cells,  bacteria,  and  such  gastric  juice  as  is  obtained  by  sponge 
absorption. 

Turck's  Bacteriological  Gyromele  does  not  differ  in  general  construc- 
tion from  the  regular  pattern.  It  is  employed  to  secure  cultures  from  any 
desired  portion  of  the  stomach  and  to  withdraw  them  without  risk  of  con- 
tamination from  other  sections. 

It  consists  of  an  English  web  tube  enclosed  in  an  outer  soft  rubber 
tube,  the  whole  provided  with  a  soft  rubber  cap  fitting  closely  over  the 
gastric  end.  After  the  instrument  has  been  brought  into  contact  with 
that  portion  of  the  alimentary  canal  from  which  it  is  desired  to  secure  cul- 
tures, the  end  of  the  tube  may  be  uncovered  by  an  attached  silk  thread,  the 
rubber  cap  removed  and  the  sponge  thus  exposed.  The  latter,  after  being 
revolved,  may  be  withdrawn  within  the  outer  soft  rubber  tube  and  the 
whole  instrument  removed  without  danger  of  contaminating  the  sponge 
from  the  esophagus  or  mouth. 

Appliances  for  Sounding. 

Sounding  of  the  Stomach  may  be  conducted  by  means  of  sounds, 
bougies,  etc.  They  may  be  employed  to  locate  curvatures  and  borders,  as- 
certain the  presence  and  extent  of  obstructions  and  determine  conditions 
generally.  While  ordinary  stomach  tubes  are  often  used  for  this  purpose, 
they  do  not  possess  enough  rigidity  to  indicate  conditions  by  the  sense  of 
touch. 

Bougies  and  sounds  should  be  of  firm  texture,  even  when  hollow,  so 
that  existing  conditions  may  be  approximated  ascertained. 


Figure  1652.     Stylet  for  Turck's  Duodenal  Sound. 

Turck's  Duodenal  Sound,  as  shown  by  figure  1652,  consists  of  a  soft  rub- 
ber stomach  tube  strengthened  by  a  spiral  stylet,  the  latter  being  em- 
ployed to  give  additional  rigidity  to  the  instrument.  Its  principal  advan- 
tage lies  in  the  readiness  with  which  it  conforms  to  the  various  curves, 
and  while  its  position  can  not  be  known  by  any  information  conveyed  at 
the  proximal  end,  its  presence  in  any  part  of  the  canal  may  be  determined 
by  palpation  during  revolution. 

Intra-Gastric  Bag  Reservoirs. 

These  consist  of  inflatable  bags  employed  to  determine  the  capacity, 
area  and  location  of  the  stomach.  They  are  of  various  forms,  according  to 
the  nature  of  the  work  involved. 


EXAMINATIONS.  711 

Turck's  Intra-Gastric  Bag  Reservoir,  an  illustration  of  which  may  be 
seen  in  figure  1653,  comprises  the  double  stomach  tube  shown  in  figure 
1645  but  has  the  gastric  end  enclosed  in  a  dilatable  bag.  The  latter 
should  be  of  thin  material  that  will  require  but  little  force  for  expansion. 


Figure  1653.    Turck's  Intra-Gastric  Bag  Reservoir. 

In  the  absence  of  an  especially  constructed  bag,  a  large  sized  capote,  if  of 
good  quality,  may  be  used  instead.  Some  authors  advise  the  ordinary 
balloon  bags  sold  by  street  venders,  but  as  a  rule,  they  have  been  found 
to  possess  too  great  a  contractile  force  and  frequently  burst. 

After  introduction  the  rubber  bag  is  filled  with  water  in  fractional  quan- 
tities of  a  quarter  liter  each,  up  to  1000  cubic  centimeters.  After  each  ad- 
dition of  water  the  line  of  gastric  dulness  may  be  located  by  percussion. 
This  determines  the  extent  and  border  of  the  greater  curvature  of  the 
stomach.  To  determine  the  lesser  curvature,  the  upper  portion  is  inflated 
with  air  through  the  smaller  of  the  two  tubes.  The  tympanic  area  will 
then  show  the  lesser  curvature,  and  by  this  means  gastroptosis  may  be 
differentiated  from  dilatation. 

Hemmeter's  Bag  Reservoir,  as  it  appears  in  figure  1654,  comprises  a 
dilatable  stomach-shaped  bag,  provided  along  its  lesser  curvature  with  a 
channel,  through  which  may  be  passed  a  curved  sound  for  use  in  the  duo- 
denum. This  latter  appliance  is  well  illustrated  in  the  figure.  As  the 
curved  tube  fits  loosely  within  the  inner  rubber  sheath,  it  may  be  extended 
through  the  bag  without  displacing  the  latter.  The  bag  is  dilated  by 
means  of  a  second  tube  attached  at  the  cardiac  end.  The  apparatus  used 
for  distending  the  bag  is  well  shown  in  the  illustration.  It  consists  of  two 
bottles,  both  graduated,  one  placed  at  some  distance  above  the  top  of  the 
other.  The  upper  contains  an  outlet  at  the  bottom  that  connects  with  the 
lower  by  suitable  tubing.  The  latter  is  provided  with  two  outlets,  one  of 
which  connects  with  the  stomach  bag.  By  filling  the  first  bottle  with 
water  and  allowing  it  to  flow  into  the  second,  the  air  in  the  latter  may  be 
forced  into  the  bag  within  the  stomach.  The  amount  of  water  passing 


712 


SURGERY    OF    THE    STOMACH. 


into  the  second  bottle  will  show,  by  the  air  displacement,  the  amount  of  air 
forced  into  the  bag  cavity. 


Figure  1654.    Hemmeter's  Bag  Reservoir. 


WASHING  OR  LAVAGE. 


Lavage  may  be  employed  for  various  reasons ;  the  technique  is  simple 
and  the  apparatus  inexpensive.  The  necessary  appliances  include  a 
stomach  tube  and  means  for  filling.  In  the  absence  of  something  better, 
a  plain  piece  of  rubber  tube  and  a  small  funnel  will  meet  every  indication. 
Suitable  stomach  tubes  are  fully  described  by  figures  1641  to  1645. 
Almost  any  form  of  reservoir  may  be  used,  and  when  desired  the  advan- 
tages of  a  T-shaped  tube  may  be  employed. 

Instead  of  the  plain  tube,  sprays  are  sometimes  utilized,  particularly  in 
the  treatment  of  gastritis. 

The  operator  ordinarily  employs  a  soft  rubber  tube  about  60  inches  in 
length  with  funnel  end.  Many  prefer  a  tube  open  at  the  end  with  several 
small  perforations  in  the  sides  of  the  tube.  The  latter  serve  to  prevent 
occlusion  as  referred  to  under  the  head  of  "  Examinations. "  After  filling 
the  stomach,  the  tube  may  be  converted  into  a  syphon  by  lowering  the 
funnel  end,  and  the  contents  evacuated. 

Turck's  Sprinkling  Tube,  as  portrayed  in  figure  1655,  belongs  to  the 
variety  of  stomach  tubes  that  are  often  referred  to  as  "needle"  douches, 
we  presume  because  they  throw  a  volume  of  fine  jets,  or  it  may  be  because 
the  openings  in  the  tube  end  are  of  needle  size.  As  neither  of  these  reas- 
ons appears  to  us  a  sufficient  cause  for  the  use  of  the  word  "needle,"  we 


LAVAGE. 


713 


employ  a  term  that  seems  to  us  correct.  The  apparatus  consists  of  a 
double  tube  constructed  on  the  plan  of  the  one  exhibited  in  figure  1645. 
The  cardiac  end  of  the  short  tube  is  supplied  with  a  small  silver  globe  con- 
taining a  large  number  of  minute  perforations.  By  connecting  the  tube 
with  a  fountain  syringe  or  other  reservoir,  if  the  latter  be  placed  at  a  suffi- 
cient height,  the  fluid  may  be  forced  through  these  openings  in  the  form 
of  fine  jets  similar  to  the  ordinary  sprinkler.  That  these  jets  may  be  di- 


Figure  1055.    Turck's  Stomach  Sprinkling  Tube. 

rected  against  all  portions  of  the  stomach  wall,  the  latter  before  use  is 
usually  distended  with  air  forced  through  the  larger  opening.  It  is  in- 
tended by  this  method  to  remove  material  from  the  stomach  wall  that  can 
not  be  dislodged  by  ordinary  lavage.  In  order  to  secure  the  proper 
amount  of  force,  the  reservoir  must  be  placed  at  a  height  of  about  12  feet 
above  the  stomach.  When  this  is  not  practicable  some  form  of  force 
pump  is  advised.  That  described  by  figure  372  will  answer  the  purpose. 


Figure  1656.    Turck's  Double  Force  Irrigator. 


Turck's  Double  Force  Irrigator,  as  set  forth  in  figure  1656,  consists  of  a 
double,  soft  rubber  stomach  tube  and  sprinkler  arranged  for  use  with  two 
reservoir  bottles,  the  connections  being  so  adjusted  that  hot  and  cold  water 
may  be  used  alternately.  The  reservoirs  are  each  supplied  with  double 
perforated  stoppers  and  tubes,  and  may  be  used  for  vacuum  or  injection  pur- 
poses. The  two  short  tubes  are  connected  with  a  single  forcing  bulb,  that 
air  pressure  may  be  exerted  in  the  bottles  and  syphons  started.  The  two 
long  bottle  tubes  are  connected  by  a  V-shaped  piece  with  one  of  the  stomach 
tubes.  Suitable  cut-offs  control  the  flow  from  either  bottle.  The  second 
stomach  tube  is  connected  with  a  vacuum  bottle  similar  to  that  employed 
for  stomach  evacuation  and  shown  by  figure  1647.  It  will  thus  be  seen  that 
either  hot  or  cold  water  may  be  used  continuously  or  alternately  as  desired. 


714  SURGERY    OF    THE    STOMACH. 

MOTOR  INSUFFICIENCY. 

This  may  be  treated  by  alternately  distending  and  contracting  the 
stomach  by  hot  and  cold  fluids.  Both  air  and  water  are  used.  For  this 
purpose  Turck  employes  an  apparatus  identical  with  that  shown  by  figure 
1653  excepting  that  the  rubber  bag  is  not  attached  to  the  gastric  end  of 
the  stomach  tube.  Either  a  rubber  forcing  bulb  or  compressed  air  may  be 
used  for  the  purpose  of  distention. 

GASTRITIS. 

Gastritis    may    be    treated  by  various  methods  among  which   are  the 
gyromele,  nebulizer   spray  and  medicated  vapors. 


Figure  1G57     Turck's  Nebulizer. 

Turck's  Nebulizer,  as  exhibited  in  figure  1657,  consists  of  a  vaporizing 
apparatus  similar  to  that  shown  in  figure  1490,  to  which  a  double  stomach 
tube  is  attached.  Owing  to  the  frequency  of  regurgitation,  it  is  necessary 
that  the  nebulizing  chamber  be  protected  from  the  natural  results  of  auto- 
expression.  This  may  be  secured  by  means  of  a  second  bottle  interposed 
between  the  first  bottle  and  the  stomach  tube,  or  a  regurgitation  chamber 
as  exhibited  in  the  illustration.  The  first  principle  was  formerly  utilized 
by  Turck,  but  as  the  second  proved  less  cumbersome  and  equally  as  effi- 
cient, it  is  now  generally  employed.  By  means  of  this  apparatus,  many 
forms  of  medicaments  may  be  applied  directly  to  the  stomach  walls.  If 
an  air-compressing  apparatus  be  employed,  the  heavier  oils  and  like  sub- 
stances may  also  be  used. 


GENERAL  ELECTRICAL  TREATMENT. 

Electricity  has  been  found  useful  by  many  practitioners.  Both  the 
direct  or  galvanic,  and  the  induced  or  Faradic  currents  are  employed. 
Bipolar  electrodes  are  advised  in  a  few  special  cases,  but,  as  a  rule,  intra- 
gastric  and  extra-abdominal  electrodes  are  preferred. 


INTRA-GASTRIC    ELECTRODES. 


715 


Einhorn's  Intra-Gastric  Electrode,  as  displayed  in  figure  1658,  consists 
of  a  small  capsular  electrode  that  is  attached  to  one  pole  of  the  battery  em- 
ployed by  means  of  a  single  connecting  wire.  It  is  intended  that  the  bulb 


Figure  1658.    Einhorn's  Intra-Gastric  Electrode.  Figure  1659.    Turck's  Intra-Gastric  Electrode. 


shall  be  swallowed  by  the  patient,  and  it  is  claimed  that  it  may  be  used 
with  patients  not  accustomed  to  the  stomach  tube. 

Turck's  Intra-Gastric  Electrode,  as  delineated  in  figure  1659,  consists  of 


\\ 


Figure  1660.    Rosenheim's  Intra-Gastric  Electrode. 


a  soft  rubber  stomach  tube  and  a  removable  spiral  conductor  somewhaf^  ^ 
after  the  pattern  of  Rosenheim.  The  electrical  mechanism  may  be  easily  r. 
removed  for  cleansing. 


-c    c 

£j 


Figure  1661.    Hayes'  Abdominal  Electrode. 


Rosenheim's  Intra-Gastric  Electrode,  as  set  forth  in  figure  1660,  consists 
of  a  specially  devised  stomach  tube,  so  arranged  that  it  may  not  only  be  used 
as  a  container  for  the  electrode  and  connecting  wire,  but  that  at  the  same 
time  water  may  be  injected  through  it  into  the  stomach.  The  electrode  is 


716 


SURGERY    OF    THE    STOMACH. 


located  within  the  gastric  end  of  the  tube,  connection  with  the  stomach 
being  made  by  numerous  small  openings.  As  the  electric  current  can  be 
conducted  to  the  stomach  walls  only  through  a  proper  medium,  it  is  neces- 
sary that  the  stomach  be  at  least  partially  filled  with  water. 

Hayes'  Abdominal  Electrode,  as  pictured  in  figure  1661,  consists  of  a  thin 
metallic  disc,  one  side  of  which  is  covered  with  spongiopiline.  The  metal 
portion  is  provided  with  radiating  slits  that  permit  of  bending  the  elec- 
trode in  any  desired  form.  This  feature  enables  the  operator  to  closely 
adjust  it  to  uneven  surfaces.  Usually  it  is  8  inches  in  diameter  and  manu- 
factured of  thin  copper  or  pure  tin. 


FORCIBLE  EVACUATION  OF  THE  STOMACH. 

This  is  employed  in  cases  of  poisoning  and  where,  for  any  reason,  it  is 
necessary  to  suddenly  empty  the  stomach  of  its  contents.  While  the  appli- 
ances generally  used  in  lavage  will  answer  in  most  cases,  many  surgeons 
prefer  some  form  of  forcing  apparatus  that  may  be  successfully  employed 
without  assistance  from  the  patient.  This  usually  consists  of  some  form 
of  pump  connected  with  a  stomach  tube. 


Figure  1662.      Author's  Improved  Stomach  Pump. 


The  Author's  Improved  Stomach  Pump,  as  portrayed  in  figure  1662,  is 
one  of  the  best  adapted  appliances  where  a  force  stronger  than  an  ordinary 
syphon  is  required.  As  the  mechanics  of  this  valveless  pump  are  described 
by  figure  372,  a  repetition  here  is  unnecessary.  The  apparatus  possesses 
sufficient  force  to  withdraw  not  only  semi-fluids,  but  such  solid  food  parti- 


STOMACH    PUMPS.  717 

•cles  as  are  small  enough  to  pass  through  the  stomach  tube.  As  it  has  no 
valves,  it  does  not  clog,  and  as  ready  means  for  quickly  reversing  the  cur- 
rent are  provided,  any  obstruction  may  be  at  once  dislodged.  By  trans- 
ferring the  free  end  of  the  tube  to  a  vessel  of  water,  the  stomach  may  be 
filled  without  removing  or  changing  the  apparatus.  By  this  means  lavage 
may  be  rapidly  repeated  as  long  as  desired 


Figure  1663.     Ordinary  Piston  Stomach  Pump. 

The  Ordinary  Piston  Stomach  Pump,  described  by  figure  1663,  exhibits 
the  old-fashioned  stomach  pump,  without  which,  in  former  years,  a  physi- 
cian's armamentarium  was  not  complete.  It  consists  of  a  piston  metallic 
pump  provided  with  a  side  outlet  pipe,  the  latter  controlled  by  a  valve 
and  lever.  By  connecting  the  pump  with  an  ordinary  stomach  tube  and 
drawing  upon  the  piston,  the  stomach  contents  are  drawn  into  the  pump 
chamber.  The  contained  fluid  may  be  expelled  through  a  side  opening 
~by  a  lever,  after  which  the  process  may  be  repeated. 


CHAPTER  XXVHI. 


NASAL  AND  NASO-PHARYNGEAL  SURGERY. 

The  various  appliances  used  in  these  departments  of  surgery  may  be 
classified  as  those  for  examinations,  treatment  of  rhinitis,  removal  of 
tumors,  correction  of  deformities,  artificial  supports,  extraction  of  foreign 
bodies,  relief  of  epistaxis,  and  tapping  of  antrum. 


EXAMINATIONS. 

Examinations  of  the  anterior  nares  and  naso-pharyngeal  cavities  require . 
Illuminating  apparatus,  see  figures  1446  to  1470. 
Speculum  for  dilating  the  nostril. 
Flexible  probe  for  examining  growths,  cavities,  etc. 
Cotton  carriers  and  cotton  for  absorbing  and  wiping  away  mucus  and 
secretions. 

And  when  the  Naso-Pharynx  is  Included: 
Tongue  depressor,  see  figures  1440  to  1445. 
Rhinoscopic  mirror. 
Palate  retractor. 

Illuminating-  Apparatus. 

Illuminating  apparatus  for  the  anterior  nares  should  consist  of  a  light 
condenser  and  reflector,  the  various  forms  of  which  are  fully  described  by 
figures  1446  to  1470.  The  reflector  need  not  differ  from  those  employed  in 
diseases  of  the  throat,  excepting  that  one  with  a  shorter  focal  distance  may 
be  utilized.  The  same  appliances  are  suitable  for  the  naso-pharynx,  the 
only  change  necessary  being  the  addition  of  a  rhinoscopic  mirror. 

Rhinoscopic  Mirrors. 

These  need  not  differ  from  the  ordinary  throat  mirrors  described  by 
figure  1468,  excepting  that,  as  a  rule,  the  reflecting  surface  should  be  more 
nearly  at  a  right  angle  with  the  handle  than  for  laryngeal  examinations. 


Figure  1664.    Michel's  Rhinoscope 


By  bending  the  flexible  shanks  of  the  ordinary  patterns,  these  will  answer 
for  every  purpose.  Special  hinged  mirrors  are  recommended  by  some 
authors. 

.  718 


NASAL    SPECULA. 


719 


Nichel's  Rhinoscope,  as  defined  in  figure  1664,  differs  from  the  ordinary 
design  employed  in  examinations  of  the  throat,  in  that  the  mirror-plate  is 
hinged  and  controlled  by  mechanism  by  which  its  reflecting  surface  may 
be  placed  at  varying  angles  with  the  shaft  of  the  instrument.  By  means 
of  a  compound  lever  controlled  by  a  thumb-blade,  the  mirror  is  controlled 
while  in  situ  without  changing  the  position  of  the  handle.  The  operator 
may  include  the  entire  pharyngeal  vault  in  a  single  sweep  of  the  mirror. 
It  may  be  obtained  in  varying  sizes,  a  mirror  y&  of  an  inch  in  diameter 
being  generally  preferred. 

Specula. 

These  usually  consist  of  valves  or  blades  arranged  with  mechanism  for 
dilating  the  flexible  portion  of  the  nostril.  Tubular  patterns  have  been 
designed,  but  have  not  met  with  general  favor.  Many  are  called  self- 
retaining,  and  while  some  of  these  retain  their  position  under  ordinary 
circumstances,  as  a  rule  they  slip  from  place  during  an  operation  as  soon 
as  the  parts  are  covered  with  blood. 


Figure  1665.    Ingals'  Speculum. 


Figure  1066.    Sajous'  Speculum. 


Ingals'  Speculum,  as  illustrated  in  figure  1665,  consists  of  two 
handles  curved  downward  terminating  in  thin  flattened  blades  with  con- 
cave inner  surfaces.  The  blades  are  about  i  ^  inches  in  length,  ^  an  inch 
in  width  at  the  base,  and  from  ^  to  ^  of  an  inch  in  width  at  their  tips. 
They  project  nearly  at  a  right  angle  with  the  handles,  while  the  shanks 
are  slightly  curved. 

Sajous'  Speculum,  as  described  in  figure  1666,  embodies  the  general 
features  of  the  pattern  of  Goodwillie,  differing  only  in  being  constructed 
with  a  screw-stop,  by  which  over-dilatation  or  excessive  pressure  is  pre- 
vented. Rings  are  provided  in  the  ends  of  the  cross-bars  so  that  it  can  be 
attached  by  means  of  threads  to  a  headband,  thus  not  only  rendering  the 
instrument  self -retaining,  but  enabling  the  operator  to  raise  the  top  of  the 
nose  where  necessary  during  operations. 


Figure  1667.    Bosworth's  Speculum. 


Figure  1668.    Straw's  Self -Retain  ing 
Speculum. 


Bosworth's  Speculum,  as  shown  in  figure  1667,  is  one  of  the  lightest  pat- 
terns in  use.  It  is  constructed  from  two  pieces  of  wire,  one  end  of  each 
being  flattened  and  joined  like  a  pair  of  spring  forceps.  The  opposite  ends 
are  curved  into  oblong  blades,  the  tip  of  each  wire  being  bent  upon  itself, 


720  NASAL    AND    NASO-PHARYNGEAL    SURGERY. 

forming  a  loop.  Two  small  discs  attached  to  the  outer  face  of  the  blades 
near  their  centers  furnish  surfaces  that  afford  a  firm  grip.  The  instrument 
is  so  light  as  to  be  self-retaining  with  many  patients  during  examinations, 
and  in  some  classes  of  operations,  thus  leaving  both  hands  of  the  operator 
free. 

Straw's  Self -Retaining  Speculum,  as  sketched  in  figure  1668,  embodies 
three  blades,  each  attached  by  a  suitable  shank  to  a  cross-bar  that  rests 
nearly  at  right  angles  with  the  long  axis  of  the  blades.  The  central  blade 
is  fixed  and  attached  to  the  middle  of  the  cross-bar.  The  latter  is  square 
and  so  arranged  that  the  two  outer  blades  may  be  caused  to  slide  backward 
and  forward,  as  desired.  The  sockets  formed  in  the  bases  of  the  sliding 
blades  are  so  shaped  that  when  pressure  is  made  in  either  direction  upon 
the  ends  of  the  blades,  they  will  remain  fixed  in  the  position  in  which  they 
have  been  previously  placed.  This  renders  them  self-locking  at  any  point, 
thus  securing  any  degree  of  dilatation  desired. 

The  object  of  the  third  blade  is  to  clamp  the  septum  and  columna  with 
a  grip  sufficient  to  furnish  an  instrument  that  is  self-retaining.  After  secur- 
ing the  septum  between  the  two  blades  of  one  side,  the  other  blade,  which 
is  then  within  the  flexible  portion  of  the  nostril,  may  be  moved  outward 
until  the  degree  of  dilatation  desired  is  secured.  As  the  instrument  is  ad- 
justable to  either  side,  it  is  almost  universal  in  its  application.  For  use 
with  the  thermo-cautery,  blades  of  additional  length  can  be  secured,  in  order 
that  the  lateral  walls  of  the  anterior  nares  may  be  entirely  protected. 

Small  nuts  are  attached  to  the  ends  of  the  cross-bars  to  prevent  the 
blades  from  becoming  completely  detached.  The  removal  of  these  nuts 
permits  separation  of  the  blades  for  the  purpose  of  cleaning.  Although 
nearly  all  patterns  of  so-called  self- retaining  specula  have  proven  defective, 
we  believe  that  this  design  will  be  accepted  with  considerable  favor  by 
specialists  generally. 


Figure  1669.    Goodwillie's  Speculum.  Figure  1670.    Jarvis'  Speculum. 


Goodwillie's  Speculum,  as  delineated  in  figure  1669,  is  a  plain  wire  spec- 
tilum  of  the  ordinary  spring  pattern,  without  screws  or  stops,  but  having  a 
third  blade,  the  distal  end  of  which  consists  of  a  small  circular  loop.  The 
intention  of  this  was  to  secure  a  self -retaining  instrument.  For  diagnostic 
uses  the  instrument  answers  a  fairly  good  purpose,  but  when  during 
operation  the  parts  become  covered  with  blood,  this,  like  many  other 
patterns  of  its  class,  easily  becomes  dislodged  from  its  position. 

Jarvis'  Speculum,  as  illustrated  in  figure  1670,  has  slender  wire-like 
blades  hinged  in  such  a  manner  that  they  may  be  spread  apart  by  compres- 
sion of  the  handles,  a  reverse  action  to  that  in  the  pattern  of  Bosworth.  A 
small  ring  encircles  the  speculum  at  the  hinged  portion,  and  is  so  adjusted 
that  when  the  blades  are  dilated,  the  ring  may  be  slipped  backward  on  the 
handles,  thus  holding  the  handles  together  and  the  blades  in  their  dilated 
position.  These  will  remain  spread  until  released  by  returning  the  ring  to 
its  original  place. 

The  instrument  is  light  and  the  fenestrae  of  the  blades  small,  the  latter 
being  only  ^  of  an  inch  in  length  by  -f$  of  an  inch  in  breadth.  The  total 


SPECULA. 


length  of  the  speculum  is  5^  inches.     Discs  are  attached  to  the  outer  mar- 
gins of  the  handles,  as  in  the  pattern  of  Bosvvorth. 

Myles'  Speculum,  as  depicted  in  figure  1671,  consists  of  a  short  cylin- 
der, the  ends  of  which  are  obliquely  cut,  while  the  whole  is  divided 
longitudinally.  The  longitudinal  sections  are  each  attached  to  arms,  which, 
after  curving  outward,  are  bent  at  right  angles  and  arranged  to  slide  one 
within  the  other,  fixation  being  secured  by  a  set-screw.  Both  of  the  blade 
terminals  are  provided  with  flanges,  the  inner  serving  to  retain  the  instru- 
ment in  situ.  It  is  evident  that  by  separating  the  arms,  a  corresponding 
divergence  is  secured  between  the  blades. 


Figure  1671.    Myles'  Speculum. 


Figure  1672.    Bishop's  Speculum. 


Bishop's  Speculum,  as  pictured  in  figure  1672,  embraces  two  self-open- 
ing blades  formed  from  a  single  piece  of  wire,  the  power  of  opening  being 
secured  by  a  spring  coil.  •  This  coil  also  forms  a  handle.  The  amount  of 
separation  is  regulated  by  a  cross-bar  and  thumb-screw.  This  is  further 
provided  with  an  inner  nut,  so  that  when  the  proper  amount  of  dilata- 
tion has  been  secured,  the  instrument  may  be  retained  in  the  desired 
position.  The  fenestrae  are  about  i  inch  in  length  by  ^  of  an  inch  in 
breadth,  the  entire  length  of  the  instrument  not  exceeding  2%  inches. 


Figure  1673.     Coulter's-Pynchon's  Speculum. 


Figure  1674.    Allen's  Specula. 


Coulter's-Pynchon's  Speculum,  as  exhibited  in  figure  1673,  comprises 
two  handles  of  the  non-crossing  variety,  curved  downward  in  bayonet 
form  and  provided  with  short  flattened  blades  that  project  at  nearly  a  right 
angle  with  the  long  axis  of  the  instrument.  These  blades  are  somewhat 
triangular  in  form,  the  peculiar  shape  being  best  explained  by  the  engraving. 
They  are  about  ^  an  inch  in  width  at  the  base  and  ^  of  an  inch  in  length. 
The  inner  surfaces  of  the  blades  are  vertically  concave,  thus  supplying  the 
greatest  possible  amount  of  operating  space  in  a  line  with  the  long  axis  of 
the  anterior  nares.  The  upper  or  outer  borders  of  the  blades  midway  be- 
tween the  base  and  point  are  provided  with  semi-spherical  protuber- 
ances, which  serve  to  engage  the  hollow  space  within  the  ventricle,  thus  ren- 
dering the  instrument  nearly  self-retaining.  The  upper  margins  of  the 
instrument  are  provided  with  olive-tipped  points  that  extend  obliquely  out- 
ward and  upward,  and  prevent  the  introduction  of  the  instrument  beyond 

46 


722  NASAL    AND    NASO-PHARYNGEAL    SURGERY. 

a  normal  depth.  The  inner  or  under  borders  of  the  blades  and  the  shanks 
are  separated  by  a  considerable  space  when  the  outer  margins  are  in  contact. 
This  form  supplies  the  greatest  possible  amount  of  operating  space,  an  advan- 
tage that  will  be  appreciated  by  many  specialists.  Two  sizes  are  provided, 
one  for  adults  and  one  for  children.  The  latter  differs  in  being  smaller 
and  in  having  the  protuberances  and  points  less  marked. 

Allen's  Specula,  as  manifest  in  figure  1674,  are  in  form  like  ovoid 
truncated  cones.  Usually  they  are  manufactured  from  hard  rubber  about 
^  of  an  inch  in  length  and  in  three  sizes,  10,  12  and  14  millimeters  in  long 
diameter  of  the  small  end. 

Probes. 

Probes  for  nasal  use  should  be  flexible,  preferably  of  silver,  that  they 
may  be  curved  or  bent  to  any  desired  shape.  They  will  be  found  useful  in 
examining  growths,  exploring  cavities,  making  examinations,  etc. 


TAUAX ft  G« 

Figure  1675.     Silver  Probe. 

The  Silver  Probe,  shown  in  figure  1675,  is  constructed  from  silver  wire, 
round  or  probe-pointed.  No  particular  pattern  is  necessary,  as  those  for 
ordinary  surgical  use  answer  every  purpose. 

Cotton  Carriers. 

These  are  employed  for  holding  masses  of  cotton  or  such  other  material 
as  may  be  selected  for  absorbing,  wiping  away  or  mopping  out  secretions. 
This  may  be  required  either  for  treatment  or  to  remove  matter  that  covers 
or  otherwise  obstructs  a  view  of  the  field  of  observation. 

For  use  in  the  anterior  nares  they  usually  consist  of  metallic  rods  with 
tips  for  engaging  and  holding  the  absorbing  substance.  Many  specialists 
supply  themselves  with  a  number  of  these  applicators,  so  that  a  clean  or 
fresh  instrument  may  be  used  in  each  case,  the  whole  number  being  steril- 
ized once  a  day. 

Cotton  carriers  for  the  naso-pharynx  need  not  differ  to  any  great  extent 
from  those -employed  in  the  throat,  as  described  on  page  651.  A  flexible 
pattern  is  often  required  for  a  case  requiring  a  special  curve.  Those  in  for- 
ceps sha.pe  are  extensively  employed.  It  is  claimed  that  cotton,  when  used 
in  this  cavity,  should  be  folded  like  gauze,  that  all  ragged  margins  may  be 
included  in  the  mass.  Layers  of  ^  by  i  inch  are  carefully  spread  flat,  all 
edges  turned  in,  and  the  whole  mass  folded  two  or  three  times,  according 
to  the  size  of  the  area  to  be  engaged.  The  more  loosely  it  is  folded,  the 
more  liquid  is  it  likely  to  absorb. 

Figure  1676.    Ingals'  Cotton  Carrier. 

Ingals'  Cotton  Carrier,  as  outlined  in  figure  1676,  is  a  copper,  nickel- 
plated  rod  about  9  inches  in  length,  square  and  tapering  for  about  two- 
thirds  of  this  distance.  The  end  is  roughened  or  threaded,  that  when  twisted 
among  the  fibers  of  cotton  or  wool,  the  latter  may  be  wound  into  a  tight 
and  close  mass.  One  advantage  possessed  by  this  pattern  is  the  low  price 
at  which  it  can  be  procured.  Though  known  in  the  market  as  Ingals'  in- 
strument, the  latter  claims  that  it  is  not  of  his  design. 


RETRACTORS. 


723 


Allen's  Cotton  Carrier,  as  shown  in  figure  1677,  is  a  wire  rod  attached 
to  a  suitable  handle,  the  distal  end  of  the  rod  being  roughened  or  constructed 
with  a  fine  thread  for  attachment  of  the  cotton. 


Figure  1G77.    Allen's  Cotton  Carrier. 


Brown's  Nasal  Applicator,  as  set  forth  in  figure  1678,  consists  of  a  round 
shaft  tapering  to  a  point,  the  latter  filed  in  a  triangular  form  with  the  sharp 
edges  slightly  serrated,  that  they  may  the  better  engage  the  cotton  mass. 
They  are  constructed  of  copper,  and  are  soft  and  flexible. 


Figure  1G78.     Brown's  Nasal  Applicator. 

Retractors. 


Retractors  for  the  soft  palate  are  required  in  certain  cases.  They  con- 
sist of  hook-shaped  instruments,  employed  for  drawing  and  holding  the 
uvula  out  of  the  field  of  vision. 


Figure  1G79.    Plain  Hard  Rubber  Retractor. 

The  Plain  Hard  Rubber  Retractor,  illustrated  by  figure  1679,  is  -  ""*•, 
hard  rubber  bar  about  |4  inch  wide,  its  distal  end  curved  at  slightly  more 
than  a  right  angle.  The  hooked  portion  should  not  exceed  S/8  of  an  inch  in 
length. 


Figure  1680.    Sajous'  Palate  Retractor. 

Sajous'  Palate  Retractor,  as  indicated  in  figure  1680,  consists  of  a  flat 
bar  with  its  terminal  end  curved  on  the  flat  in  hook  form.  It  is  provided 
with  a  lateral  hinge,  by  which  the  shaft  may  be  curved  to  the  right  or  left, 
that  the  hand  of  the  operator  may  not  obstruct  the  field  of  vision.  The' 
lateral  margins  of  that  part  of  the  shaft  which  comes  in  contact  with  the 
soft  palate,  are  provided  with  wings  or  flanges  that  project  upward 
to  serve  as  guides,  and  hold  the  uvula  between  them.  The  entire  instrument 
is  about  7  inches  in  length. 

White's  Self -Retaining  Palate  Retractor,  as  displayed  by  figure  1681, 
consists  of  a  square  shaft  terminating  in  a  wire  loop  that  is  sharply  curved 
upon  the  flat.  This  loop  gradually  widens  outward  until  its  terminal  bor- 
der is  almost  circular  in  form.  The  shaft  is  provided  with  a  sliding  collar, 


NASAL    AND    NASO-PH ARYNGEAL    SURGERY. 

to  the  distal  end  of  which  two  arms  are  attached,  each  terminating-  in  an 
oval  fenestra,  the  whole  fitting  over  the  tipper  lip  in  such  a  manner  that, 
after  the  instrument  is  adjusted  by  means  of  a  set  screw,  it  may  be  made 
self-retaining.  The  handle  of  the  instrument  is  jointed,  that  its  extreme 


Figure  1C81.     White's  Self-Retaining  Palate  Retractor. 

proximal  end  may  not  interfere  with  the  operator.  The  instrument  is  of  as 
light  construction  as  is  consistent  with  the  necessary  strength.  It  cannot 
be  used  in  cases  where  the  tipper  incisors  are  missing,  or  on  patients  with 
a  receding  upper  lip. 


TREATMENT  OF  RHINITIS. 

This,  whether  acute,  chronic,  intumescent  or  hypertrophic,  may  be  re- 
lieved by  medicated  applications  or  surgical  interference.  The  appliances 
utilized  in  local  medicinal  treatment,  either  prophylactic  or  palliative, 
consist  of: 

Illuminating  apparatus,  figures  1446  to  1470. 

Speculum  for  dilating  nostril,  figures  1665  to  1674. 

Probe  for  examination  of  growths,  cavities,  etc. ,  figure  1675. 

Cotton  carriers  and  cotton  for  removing  secretions,  figures  1676  to  1678. 

Applicator  for  chemical  caustics,  figures  1682  to  1687. 

Douche  or  syringe. 

Spray  or  atomizer. 

Powder  blower. 

Surgical  Interference,  when  necessary  to  remove  redundant  tissue, 
will  require  one  or  more  of  the  following  instruments  • 

Septometers  for  determining  thickness  of  septum. 

Hypodermic  syringe  for  the  application  of  cocaine. 

Dressing  forceps  for  removal  of  foreign  bodies. 

Seizing  or  grasping  forceps. 

Snare  (cold)  for  removal  or  ecrasement  of  tumor  masses. 

Transfixion  needles  for  holding  protruding  masses. 

Knife  for  excisions. 

Curette  for  removal  of  soft  tumor  masses. 

Cutting  forceps  for  removing  redundant  cartilaginous  tissues. 

Scissors  for  general  excisions. 

Hemostatic  clamp  in  cases  of  hemorrhage. 

Galvano-cautery. 

If  exostosis  or  ecchondrosis  be  present,  the  operator  in  addition  may 
require : 

Saw. 

Electro-motor. 

Chisel. 


TREATMENT    OF    RHINITIS. 


725 


Gouge. 
Spud. 
Spatula. 
Dilators. 
Nasal  tubes. 

If  adenoid  hypertrophy  requires  operation,  the  surgeon  should  also  be 
provided  with : 

Mouth  gag,  see  figures  1524  to  1527. 
Palate  retractor,  see  figures  1679  to  1681. 
Appliances  for  anesthesia,  see  figures  329  to  351. 

Applicators. 

Applicators  for  chemical  caustics  vary  in  construction  according  to  the 
nature  of  the  caustic  to  be  applied.  A  design  that  may  be  advantageously 
used,  particularly  in  the  post-nasal  space,  is  described  by  figure  1516. 


Figure  1682.     Sajous'  Chromic  Acid  Appli 


Sajous'  Chromic  Acid  Applicator,  as  it  appears  in  figure  1682,  is  a 
straight  tube  about  3^  inches  in  length,  in  the  center  of  which  a  slender 
shaft  is  caused  to  actuate  by  suitable  mechanism.  This  shaft  terminates 
in  a  tongue-shaped  silver  tip,  upon  which  the  acid  is  fused  after  first  being 
melted  by  heat.  A  spring  within  the  handle,  when  in  free  action,  draws 
the  tongue  within  the  tip  of  the  instrument.  Pressure  upon  this  spring 
forces  the  shaft  forward  and  causes  extension  of  the  caustic-charged  point. 
The  amount  of  extension  is  regulated  by  a  set-screw  placed  beneath  the 
spring.  The  curved  tip  may  be  rotated  so  as  to  point  in  any  desired  direc- 
tion. 


Figure  1083.      Sajous'  Glacial  Acetic  Acid  Applicator. 

Sajous'  Glacial  Acetic  Acid  Applicator,  as  drawn  in  figure  1683,  com- 
bines a  suitable  shaft  and  handle,  the  former  longitudinally  divided  into 
two  equal  parts.  One  section  is  fixed,  while  the  other  is  caused  to  actuate 
or  slide  backward  or  forward,  its  movement  being  controlled  by  a  spring 
lever  attached  to  the  moving  shaft  within  the  handle.  The  inner  surfaces 
of  the  two  sections  forming  the  shaft  necessarily  present  flat  surfaces 
each  to  the  other,  a  sliding  clamp  holding  them  in  close  contact.  The 
tips  or  distal  ends  are  widened  into  spatula-shaped  blades,  the  face  or  sur- 
face of  the  fixed  blade  containing  a  number  of  small  holes  or  depressions 
sufficient  to  hold  a  drop  of  acid.  While  being  introduced,  this  surface  is 
covered  by  the  opposite  plate.  After  being  passed  and  brought  in  contact 
with  the  surfaces  to  be  cauterized,  by  pressing  upon  the  spring,  the  charged 
acid  surface  is  uncovered  and  the  acid  applied  directly  to  the  desired 
parts  by  contact  and  absorption.  The  flattened  ends  should  be  constructed 
of  silver.  All  free  acid  on  the  outside  of  the  applicator  should  be  carefully 
removed  before  introduction. 


726 


NASAL    AND    NASO-PHARYNGEAL    SURGERY. 


Bosworth's  Acid  Applicator,  as  shown  in  figure  1684,  is  a  flattened  wire 
rod  bent  at  an  angle  of  about  145°.  It  is  employed  particularly  for  the  ap- 
plication of  chromic  acid.  By  dipping  the  point  of  the  probe  in  mucilage 


Figure  1084.      Bosworth's  Acid  Applicator. 

and  bringing  it  in  contact  with  chromic  acid,  the  latter  will  adhere  to  the 
probe,  when  it  may  be  heated  and  fused  into  a  bead. 

Gleistman's   Acid   Applicators,  as  portrayed  in  figure  1685,  comprise  a 
set  of  six  shafts,  usually  manufactured  from  aluminum  and  curved  for  vari- 


Figure  1685.    Gleistman's  Acid  Applicators. 

ous  uses  in  the  throat,  nose  and  naso-pharynx.  The  tips  are  all  bored  in 
cylindrical  form,  and  a  portion  of  them  contain  side  openings  near  the 
point,  so  that  if  the  tube  be  filled  with  acid,  application  may  be  made 


Figure  1686.    Webster's  Glacial  Acetic  Acid  Applicator. 

laterally  along  the  diseased  surfaces.  The  various  shapes  are  shown  in  the 
illustration.  A  universal  handle  with  set  screw  forms  a  portion  of  the 
apparatus. 


Figure  1687.    Bosworth's  Chromic  Acid  Applicator. 

Webster's  Glacial  Acetic  Acid  Applicator,  as  represented  by  figure  1686, 
consists  of  a  slender  shank  terminating  in  a  thin  blade  of  spatula  shape,  both 
sides  of  which  are  covered  with  fine  longitudinal  grooves,  which  serve  to 


NASAL  DOUCHES. 


727 


hold  the  acid  for  application.    The  instrument  is  plain  and  of  simple  con- 
struction, is  sold  at  a  low  price,  and  yet  seems  to  answer  every  purpose. 

Bosworth's  Chromic  Acid  Applicator,  as  drawn  in  figure  1687,  consists  of 
a  tube  within  which  a  shaft  is  caused  to  actuate,  the  whole  presenting  a  full 
post-nasal  curve.  The  tip  of  the  tube  is  flattened  and  flaring,  and  forms  a 
recess  in  which  the  acid-bearing  cup  finds  a  secure  lodgment.  The  pos- 
terior end  of  the  tube  is  enlarged  into  a  chamber  that  contains  a  coiled  wire 
spring,  by  which  the  shaft  is  maintained  in  a  retracted  and  concealed  posi- 
tion. As  the  shaft  extends  proximally  beyond  the  tube  ending,  by  pushing 
on  the  latter,  the  tip  may  be  protruded  to  any  desired  extent.  That  the 
amount  of  exposure  of  the  tip  may  be  regulated,  the  shaft  terminal  is 
provided  with  a  sliding  ring  and  set  screw  that  may  be  fixed  at  any  point 
on  that  portion  of  the  shaft  external  to  the  tube  ending.  A  handle  is  at- 
tached to  the  right  lateral  margin  of  the  proximal  portion  of  the  cylinder. 
The  cup  is  of  silver  and  shaped  like  a  shallow  spoon,  with  its  concavity  on 
the  posterior  border. 

Douches. 

These  may  be  obtained  in  designs  varying  from  the  reservoir  of  Thud- 
icum  to  the  small  curved  glass  tubes  shown  by  figure  1693. 

Thudicum's  Douche,  as  will  be  seen  by  referring  to  figure  1688,  is  perhaps 
the  most  common  of  this  class  of  instruments.  It  is  a  glass  bottle  provided 


Figure  1688.    Thudicum's  Douche. 


Figure  1689.    Siphon  Douche. 


with  an  outlet  at  the  bottom,  to  which  is  attached  a  rubber  hose  supplied 
with  a  suitable  nasal  pipe.  They  may  be  purchased  in  sizes  varying  from 
one  pint  to  half  a  gallon. 

The  Siphon  Douche,  as  shown  in  figure  1689,  is  a  soft  rubber  hose  pro- 
vided in  its  center  with  a  small  exhaust  bulb  and  connecting  at  its  distal 
end  with  a  weight  and  a  U-shaped  support,  by  which  the  hose  may  be  secure- 
ly attached  to  a  pitcher,  pail,  or  other  suitable  vessel.  The  apparatus  as 
generally  manufactured  is  provided  with  a  bulb-shaped  nasal  pipe.  The 
flow  is  started  by  compression  of  the  rubber  bulb. 

Dessaire's  Douche  Cup,  as  shown  by  figure  1690,  is  a  small  glass  or  por- 
celain cup  with  a  long  spout  ending  in  a  tip  of  such  form  that  it  may  be 


728 


NASAL    AND    NASO-PH ARYNGEAL    SURGERY. 


pressed  into  the  anterior  naris.     These  cups  usually  hold  from  2  to  3  ounces, 
a  quantity  sufficient  for  many  cases. 


~~ 


Figure  1690.    Dessaire's  Douche  Cup. 


Figure  1691.    Birmingham  Douche. 


The  Birmingham  Douche,  illustrated  by  figure  1691,  consists  of  a  glass 
cylinder  about  i  inch  in  diameter,  both  ends  of  which  are  contracted  into 
narrow  openings.  The  one  forming  the  handle  of  the  douche  is  the  larger 
of  the  two,  and  is  used  as  a  funnel  for  filling.  The  nasal  end  is  bent  up- 
ward, quite  conical  in  form  with  a  bayonet  curve,  the  tip  being  of  such 
form  as  to  fit  closely  into  the  external  naris.  The  lower  side  of  the  instru- 
ment is  slightly  flattened  that  it  may  rest  on  a  table  or  stand  without  dan- 
ger of  overturning.  As  the  instrument  is  manufactured  on  a  large  scale,  it 
is  sold  at  a  low  price. 


Figure  1692.    Elastic  Douche. 


Figure  1693.    Test  Tube  Douche. 


The  Elastic  Douche,  explained  in  figure  1692,  comprises  a  small  reser- 
voir and  nasal  pipe,  connected  by  a  piece  of  rubber  hose.  The  reservoir 
pipe  and  tube  are  filled  with  the  fluid  to  be  injected,  and  the  tip  placed  in 
the  naris.  The  reservoir  is  now  placed  to  the  lips,  and  by  blowing  into 
it,  the  contents  are  expelled  into  the  nasal  cavity. 

The  Test  Tube  Douche,  illustrated  in  figure  1693,  consists  of  a  glass  pipe 
similar  in  shape  to  that  of  an  ordinary  test  tube,  the  lower  end  of  which  is 
enlarged  into  a  small  bulb  and  provided  with  an  opening  or  outlet  at  its  tip. 
The  pipe  is  bent  at  an  acute  angle  near  its  center.  The  amount  of  fluid 
required  for  an  application  may  be  poured  into  the  tube,  the  bulbous  portion 
inserted  into  the  nostril,  the  head  thrown  back,  and  the  contents  allowed  to 
pass  into  the  nasal  cavity. 

Syring-es. 

Syringes  for  use  in  the  nares  may  be  of  the  fountain,  bulb,  piston,  or 
any  other  desired  pattern.  Generally,  the  fountain  syringe  is  preferred, 
because  it  supplies  an  even,  uninterrupted  flow,  the  quantity  of  fluid  passed 
being  regulated  only  by  the  size  of  the  syringe  bag. 

The  Fountain  Syringe  with  Nasal  Pipes,  as  shown  in  figure  1694,  is  a 
soft  rubber  bag  with  a  capacity  of  two  quarts,  connected  with  a  nasal  pipe  by 
a  soft  rubber  hose.  A  cut-off  controls  the  flow.  The  amount  of  force 


NASAL    SYRINGES. 


729 


employed  depends  upon  the  height  at  which  the  bag  is  suspended  above  the 
point  where  the  water  escapes  from  the  pipe. 


Figure  1694.    Fountain  Syringe  with  Nasal  Pipes. 

Warner's  Post-Nasal  Syringe,  as  presented  in  figure  1695,  consists  of  a  sig- 
moid  hard  rubber  tip  attached  to  a  small,  plain  bulb.  The  post-nasal  end  of 
the  syringe  pipe  is  sharply  curved  upward  and  provided  with  numerous 


Figure  1695.    Warner's  Post-Nasal  Syringe. 

small  openings,  through  which  liquids  may  be  forced  in  fine  jets  under  hand 
pressure.  By  compressing  the  bulb  and  placing  the  tip  below  the  surface  of 
the  fluid  to  be  injected,  the  bulb  may  be  filled  upon  release  of  the  hand  press- 
ure 


Figure  1696.    Scheppegrell's  Nasal  Syringe. 

Scheppegrell's  Nasal  Syringe,  as  outlined  in  figure  1696,  comprises  an 
ordinary  bulb  syringe  with  a  flexible  catheter-like  rubber  tube,  the  latter 
provided  with  numerous  side  openings,  through  which  fine  jets  of  fluid 
may  be  forced. 


Figure  1697.    "Success"  Catheter  Syringe. 


The  " Success"  Catheter  Syringe,  illustrated  by  figure  1697,  combines 
the  bulb  employed  in  the  Warner  syringe  and  the  elastic  rubber  tube  of  the 


730 


NASAL    AND    N ASO-PH ARYNGEAL    SURGERY. 


Scheppegrell  pattern,  previously  described.  The  instrument  is  generally 
considered  an  improvement  on  the  former,  and,  unless  copious  irrigation 
is  desired,  more  convenient  than  the  latter. 

Sprays,  Nebulizers,  Etc. 

Spray  tubes,  nebulizers,  etc. ,  having  been  fully  described  and  illustrated 
by  figures  1484  to  1495,  no  further  reference  to  them  is  required  in  this 
chapter. 

Atomizers. 

These,  like  the  spray  tubes  above  referred  to,  are  described  by  figures 
1496  to  1503.  Those  intended  especially  for  making  applications  to  the  an- 
terior nares  are  usually  provided  with  some  form  of  bulbous  tip,  the  inser- 
tion of  which  closes  the  nostril. 


Figure  1698.    Bishop's  Camenthol  Inhaler. 

Bishop's  Camenthol  Inhaler,  as  outlined  in  figure  1698,  is  a  glass  cylin- 
der about  4  inches  in  length,  and  arranged  to  contain  medicated  sponges  or 
other  absorbents,  through  which  inspired  nasal  air  may  be  caused  to  pass. 
The  body  of  the  tube  is  usually  filled  with  pieces  of  sponge,  between  which 
the  medicament  in  crystal  form  may  be  placed,  or  the  sponges  may  be  satu- 
rated with  a  solution  of  any  desired  strength.  Two  cork  rings  placed  within 
the  tube  near  each  end  serve  to  hold  the  sponges  in  place,  the  openings 
through  them  being  large  enough  to  admit  the  free  passage  of  air.  Corks 
in  each  end  prevent  the  escape  of  the  medicated  vapors  when  the  instru- 
ment is  not  in  use.  By  removing  the  corks,  placing  one  end  within  the 
nostril,  and  closing  the  other  nostril  diiring  inspiration,  air  charged  with 
the  medicament  may  be  drawn  through  the  natural  passages. 

Powder  Blowers. 

As  almost  any  form  of  powder  blower  may  be  used  when  introducing 
powder  into  the  nares,  we  will  refer  the  reader  to  figures  1505  to  1510, 
where  they  have  been  fully  illustrated. 

Septometers. 

These  consist  of  calipers  employed  to  estimate  the  amount  of  hypertro- 
phic  redundancy  in  either  nostril.  The  measurements  are  made  compara- 
tive by  also  ascertaining  the  size  of  the  canal  opposite  the  unaffected  por- 
tions of  the  septum. 


Figure  1699.     Seller's  Septometer. 

Seller's  Septometer,  as  noted  in   figure    1699,  consists  of  two  crossing 
blades  in  caliper  form,  the  terminal  ends  supplied  with  a  quadrant  cross-bar. 


NASAL    DRESSING  FORCEPS. 


731 


The  latter  is  grachiated  in  millimeters  and  supplied  with  a  marker,  by  means 
of  which  the  distances  between  the  terminal  ends  of  the  blades  may  be  accu- 
rately shown.  By  passing  the  instrument  within  the  nostrils,  the  thickness 
of  the  septum  may  be  determined. 

Cocaine  Syringes. 

These  may  be  of  various  patterns.     Usually  the  discharge  pipe  is  better 
if  flexible  and  blunt-pointed. 


Figure  1700.    Ingals'  Cocaine  Syringe. 

Ingals'  Cocaine  Syringe,  as  indicated  in  figure  1700,  is  particularly  appli- 
cable for  the  introduction  of  cocaine  against  the  bases  of  nasal  polypi.  As  the 
canula  is  of  pure  silver,  it  is  soft  and  flexible,  thus  permitting  any  desired 
curve.  It  may  be  bent  to  apply  cocaine  to  any  part  of  the  nares,  or  to  throw 
solutions  into  cavities,  against  the  base  of  tumors,  etc.  It  may  also  be  util- 
ized for  the  introduction  of  cocaine  into  any  of  the  smaller  natural  cavities 
of  the  body  or  into  sinuses  or  other  contracted  openings. 

Dressing  Forceps. 

These  are  slender  instruments  employed  for  removing  foreign  bodies, 
for  cotton  carriers,  etc.  Usually  they  have  slender  blades,  bent  or  curved 
at  such  an  angle  that  the  hand  of  the  operator  will  not  obstruct  the  field  of 
vision. 


Figure  1701.    Ingals'  Dressing  Forceps. 


Figure  1702.    Hartman's  Dressing  Forceps. 

Ingals'  Dressing  Forceps,  as  displayed  in  figure  1701,  are  of  slender  con- 
struction, about  6  inches  in  length,  with  handles  curved  at  an  angle  of  about 
135°.  The  handles  and  shanks  are  strong,  with  short,  narrow  serrated  jaws, 


732  NASAL  AND  NASO-PHARYNGEAL  SURGERY. 

presenting  double  concave  surfaces  with  small  openings  or  fenestrse,  by 
means  of  which  the  instrument  may  be  employed  as  a  thread  or  ligature 
carrier. 

Hartman's  Dressing  Forceps,  as  shown  in  figure  1702,  differ  from  the 
pattern  of  Ingals  in  being  curved  downward  on  the  edge  instead  of  on  the 
flat.  The  blades  are  delicate  and  have  slender  jaws,  the  inner  surfaces 
of  which  are  longitudinally  grooved,  while  the  margins  are  transversely 
serrated. 

Seizing  Forceps. 

These  differ  from  the  dressing  forceps  last  described  in  being  constructed 
with  mouse-  or  tenaculum-shaped  teeth.  They  are  employed  for  the  manipu- 
lation of  tissues,  usually  during  excision. 


Figure  1703.    Wilson's  Tissue-Holding  Forceps. 


Wilson's  Tissue-Holding  Forceps,  as  represented  in  figure  1703,  are  of 
medium  weight,  about  7  inches  in  length,  curved  upon  the  edge  and  con- 
structed with  long,  slender  serrated  jaws  terminating  in  mouse-teeth.  This 
instrument  is  particularly  adapted  for  grasping  and  holding  masses  of  soft 
tissue  within  the  anterior  nasal  passage.  It  may  be  employed  for  holding 
such  tissues  during  excision  with  knife,  gouge,  chisel,  or  galvano-cautery 
knife. 

Snares. 

A  snare  consists  of  a  loop  of  wire  or  other  suitable  material  with  mechan- 
ism by  which  the  loop  may  be  reduced  in  size  and  any  enclosed  tissues  sub- 
jected to  ecrasement  or  division,  as  desired.  They  are  employed  in  nasal 
surgery  to  remove  redundant  tissues.  Ordinary  No.  5  piano  wire  is  usually 
employed.  It  is  of  steel,  highly  tempered,  and  furnishes  a  loop  not  only  of 
sufficient  strength,  but  of  a  degree  of  stiffness  that  enables  it  to  be  carried 
over  or  around  growths,  where  it  will  usually  retain  its  position. 


Figure  1704.    Jarvis'  Snare. 

Jarvis'  Snare,  as  disclosed  by  figure  1704,  is  a  tubular  shaft  with  walls 
of  sufficient  thickness  to  admit  the  cutting  of  an  external  thread  for  about 
two-fifths  of  its  length.  A  double- winged  enlargement  near  the  center  fur- 
nishes means  for  controlling  the  rotation  of  the  shaft.  A  sliding  collar 
moved  by  a  milled  nut  is  caused  to  travel  backward  or  forward  over  the 
threaded  portion.  The  two  ends  of  the  wire  forming  the  loop  may  be  passed 
through  the  entire  length  of  the  instrument  and  attached  to  pins  or  posts 


NASAL    SNARES. 


733 


secured  in  the  proximal  end  of  the  sliding  collar  previously  referred  to. 
After  the  loop  is  drawn  tight  and  the  ends  of  the  wire  secured,  by  turning 
the  milled  nut,  the  loop  may  be  drawn  entirely  within  the  canula.  This  pat- 
tern may  be  obtained  either  with  or  without  a  curved  tip.  As  it  is  one  of 
the  lightest  of  this  class  of  instruments,  it  is  not  extensively  used. 


Figure  1705.    Sajou's-Jarvi's  Snare. 


The  Sajou's-Jarvi's  Snare,  as  exhibited  by  figure  1705,  is  an  improvement 
on  the  pattern  of  Jarvis.  It  consists  of  a  tubular  shaft  supplied  with  an  in- 
ner rod  controlled  by  a  milled  nut,  by  which  forcible  retraction  of  the  rod  is 
secured.  Two  tubes  are  provided,  one  straight,  the  other  curved,  through 
which  the  rod  is  caused  to  actuate.  A  short  piece  of  wire  may  be  used  for 
the  loop,  an  eye  being  provided  in  the  end  of  the  rod,  to  which  the  wire  may 
easily  be  secured.  As  the  tubes  have  only  a  single  opening,  complete  division 
of  tissue  may  be  secured.  It  is  a  heavier  pattern  than  that  of  Jarvis  and  con- 
sequently better  adapted  for  general  work. 


Figure  1706.    Bosworth's  Snare. 


Bosworth's  Snare,  as  seen  in  figure  1706,  consists  of  a  square  shaft  curved 
at  its  distal  end  at  an  angle  of  about  135°,  and  provided  with  a  slip  joint, 
by  means  of  which  either  a  curved  or  straight  tube  may  be  attached  and  se- 
cured with  a  set  screw.  The  corners  of  the  square  shaft  are  threaded,  a 
milled  nut  plying  along  the  same.  A  square  sliding  collar  provided  with 
finger  rings  may  be  moved  backward  and  forward  along  the  shaft.  The 
upper  of  these  rings  is  provided  with  two  posts,  to  which  the  ends  of  the 
wire  forming  the  loop  are  attached.  The  proximal  end  of  the  shaft  is  pro- 
vided with  a  thumb  ring.  The  instrument  is  strong  in  construction  and 
much  heavier  than  either  of  the  patterns  previously  referred  to. 

Ingals'  Snare,  a  likeness  of  which  may  be  seen  in  figure  1707,  is  a  modi- 
fication of  the  pattern  of  Bosworth,  differing  principally  in  being  provided 
with  six  tips  instead  of  two,  and  in  spreading  the  proximal  ends  of  the  wire 
loop,  fastening  them  to  pins  adjusted  in  the  outer  borders  of  the  two  finger 
rings.  This  is  an  advantage,  because  the  traction  force  is  thus  equally  dis- 
tributed upon  both  sides  of  the  sliding  collar.  Any  other  arrangement  in 


734 


NASAL    AND    N ASO-PH AR YNGEAL    SURGERY. 


snares  of  this  character,  forces  the  collar  to  bind  upon  the  side  on  which 
the  snare  wires  are  not  attached,  and  frequently  interferes  with  the  success- 
ful operation  of  the  instrument.  Of  the  six  tubes,  two  are  straight,  one  fine, 
the  other  coarse ;  one  slightly  curved,  one  bent  at  a  right  angle,  another 


Figure  1707.    Ingals'  Snare. 


with  a  long  sweeping  curve,  while  the  last  is  abruptly  curved  that  it  may 
be  employed  in  the  posterior  nares.  As  now  made,  the  main  shaft,  or 
threaded  portion,  is  fully  6  inches  in  length,  thus  permitting  the  closing  of 
large  loops.  The  thread  is  fine,  and  thus  great  power  is  secured. 


Figure  1708.    Hobby's  Snare. 

Hobby's  Snare,  as  will  be  seen  by  consulting  figure  1708,  is  constructed 
on  the  plan  of  the  well-known  French  ecraseur.  It  is  a  small  instrument 
of  light  construction,  but  possesses  great  strength.  It  consists  of  a  tubular 
steel  shaft,  to  the  distal  end  of  which  tubes  may  be  attached  by  slip  joints 
and  a  set  screw.  Two  of  these  tubes  are  straight,  of  different  lengths,  the 
third  being  slightly  curved.  A  threaded  rod  terminating  in  a  fixed  block  is 
caused  to  move  backward  and  forward  by  means  of  a  milled  nut,  the  lat- 
ter provided  with  spokes  by  which  any  degree  of  power  required  may  be 
obtained.  The  rod  being  double  threaded,  rapid  action  may  be  secured. 

The  sliding  block  referred  to  is  provided  with  three  openings  with  fine 
slots,  in  which  the  wire  may  be  easily  and  securely  fastened.  The 
only  disadvantage  is  that  as  it  is  operated  by  screw  power  alone,  soft  tissues 
cannot  be  severed  with  a  thumb  and  finger  movement.  Where  great  power 
in  a  light  instrument  is  desired,  it  will  fill  every  requirement. 

Sajous'  Snare,  as  illustrated  in  figure  1709,  differs  from  the  pattern  pre- 
viously described  in  being  operated  by  a  scissors-handle  movement.  The 
instrument  consists  of  two  shanks,  angular  bent  on  the  edge,  to  the  lower  or 
fixed  one  of  which  tubes  may  be  attached  by  a  slip  joint  and  thumb  screw. 


NASAL    SNARES. 


735 


The  tubes  are  three  in  number;  one  straight,  one  curved  at  a  right  angle, 
the  other  full  curved  for  use  in  the  posterior  nares.  The  tips  of  the  tubes 
are  flattened,  each  being  provided  with  lateral  slots  into  which  the  wire  loop 
may  be  drawn  when  it  is  necessary  to  completely  divide  the  included  tis- 
sues. Two  central  rods,  straight  and  curved,  are  provided,  by  means  of 
which  the  wire  is  retracted.  These  rods  pass  through  the  tubes  previously 
referred  to,  and  are  securely  fastened  to  a  collar  adjusted  to  the  thumb  blade 
of  the  handles.  The  wire  loop  to  be  used  is  attached  to  the  end  of  one  of 

cr 


Figure  1709.    Sajous'  Snare. 


the  central  rods.  Thus  arranged,  the  instrument  may  be  passed  into  posi- 
tion and  the  wire  loop  adjusted,  after  which  it  may  be  tightly  drawn  by 
thumb  and  finger  movement,  and  unless  the  tissues  are  found  too  dense, 
they  may  be  divided  by  this  means.  If  this  be  not  sufficient,  the  amount  of 
constriction  secured  may  be  maintained  by  use  of  the  cross-bar  and  fly  nut 
connecting  the  handles.  Thus  securely  held,  the  operation  may  be  com- 
pleted by  turning  the  milled  nut,  which  forms  a  portion  of  the  collar.  This 
arrangement  enables  the  surgeon  to  sever  denser  tissues  with  screw  power. 


Figure  1710.    Moscrop's  Snare  and  Ecraseur. 

Moscrop's  Snare  and  Ecraseur,  as  set  forth  in  figure  1710,  combines  the 
principles  of  a  hoisting  drum  in  combination  with  a  wire  noose,  the  latter 
confined  within  a  tube  after  the  manner  of  ordinary  surgical  snares.  The 
drum  is  caused  to  revolve  by  closure  of  the  handles,  the  latter,  when  free 
from  hand  pressure,  being  opened  by  a  strong  steel  spring.  The  upper 
handle,  to  which  the  snare  tube  and  drum  are  attached,  forms  the  fixed 
portion  of  the  instrument.  The  drum  is  transversely  perforated  to  receive 
the  ends  of  the  wire  forming  the  loop,  and  is  supplied  with  two  lateral  cog- 
wheels in  disc  form.  The  lower  handle  is  attached  to  the  main  body  of  the 
instrument  by  a  hinged  joint,  and  is  arranged  to  carry  a  lever  that  by  con- 
tact with  the  cog  teeth,  serves  to  revolve  the  drum  upon  which  the  wire  is 
wound.  A  dog  controlled  by  a  push-button  prevents  the  drum  from  revers- 


736 


NASAL  AND  N ASO-PHARYNGEAL   SURGERY. 


ing  until  released.  The  snare  tubes  are  two  in  number,  for  coarse  and  fine 
wire,  and  when  in  service,  are  secured  to  the  upper  handle  by  a  set  screw. 
These  tubes  are  slotted  and  contain  a  small  short  bar  to  which  the  drum  wire 
is  attached.  The  distal  end  of  this  bar  is  arranged  to  project  beyond  the  tube 
ending,  the  terminal  portion  being  flattened  and  provided  with  eyes 
through  which  a  piece  of  wire  long  enough  to  form  the  necessary  loop  may 
be  threaded.  This  not  only  enables  the  surgeon  to  utilize  a  short  piece  of 
wire  in  each  operation,  but  saves  the  time  and  annoyance  of  threading  the 
entire  wire  whenever  the  instrument  is  wanted  for  use.  This  bar  is  pro- 
vided with  a  side  projection  that  extends  through  the  slot.  This  serves  a 
two-fold  purpose.  By  means  of  this  lateral  projection  the  bar  may  be 
moved  backward  and  forward  along  the  tube  by  thumb  and  finger  move- 
ment, it  also  enables  the  surgeon  to  use  the  instrument  as  a  constrictor  by 
twisting  the  wire  around  the  enclosed  tissues.  From  this  description  it  will 
be  seen  that  this  instrument  offers  unusual  advantages.  It  is  rapid  in  its 
action,  simple  in  its  mechanism  and  of  sufficient  power  not  only  for  nasal 
and  laryngeal,  but  for  uterine  polypi.  It  possesses  the  further  advantage 
that  it  may  be  used  either  as  a  plain  constrictor  or  for  purposes  of  ex- 
cision. 


Figure  1711.    Stork's  Laryngeal  Snare  and  Ecraseur. 


Stork's  Laryngeal  Snare  and  Ecraseur,  as  represented  in  figure  1711, 
consists  of  a  strong  steel  shaft  provided  with  a  swiveled  thumb-ring  and  a 
sliding  finger-bar  of  such  shape  and  construction  as  to  furnish  all  the  force 
and  strength  required  for  snaring  purposes.  The  shaft  is  constructed  with 
six  sides,  thus  decreasing  the  amount  of  the  lateral  pressure  of  the  sliding 
collar  and  consequently  reducing  the  amount  of  friction  when  the  snare  is 
in  operation.  One  of  the  rings  attached  to  the  sliding  bar  is  open,  thus 
allowing  greater  freedom  in  opening  and  closing  the  fingers.  The  tubes 
are  three  in  number,  straight,  post-nasal  and  laryngeal. 

The  striking  feature  of  this  instrument  are  the  tips,  which  are  of  spe- 
cial construction,  designed  with  a  view  to  assisting  in  the  proper  placing  of 
the  wire  loop.  Four  are  provided,  each  representing  a  loop  divided  into 
halves  by  a  longitudinal  slot.  Two  of  these  loops  are  straight,  while  two  are 
curved  upon  the  flat.  The  fenestrae  are  of  sufficient  size  to  enable  the  oper- 
ator to  slip  them  over  or  around  any  tissues  to  be  removed.  The  walls 
of  the  fenestrae  may  thus  serve  as  introducers  or  guides  for  the  wire  loops. 

When  in  use,  the  selected  tip  is  screwed  into  place  and  the  wire  loop  so 
adjusted  as  to  lie  within  the  slotted  wall  of  the  fenestra,  in  which  condition 


TRANSFIXION    NEEDLES — KNIVES. 


737 


the  loop  is  passed  over  the  tissues  to  be  removed,  when,  by  tightening  the 
wire  ends  and  fastening  them  to  the  sliding  bar,  the  parts  may  be  severed  by 
thumb  and  finger  movement.  One  of  the  tips  is  small,  straight  and  with- 
out fenestrae,  designed  particularly  for  ecrasement  where  complete  division 
of  the  tissues  is  not  desired.  The  fenestrae  of  the  straight  tips  are  8  and 
13  millimeters  in  lateral  diameter,  while  those  of  the  curved  tips  are  10  and 
13  millimeters,  respectively. 


Figure  1712.     Flat  Nose  Pliers  with  Paiaiiel  Jaws. 

The  Flat  Nose  Pliers,  exhibited  in  figure  1712,  are  of  such  construction 
that  the  jaws  move  laterally  on  both  opening  or  closing.  This  pattern  is 
particularly  adapted  for  use  with  a  nasal  snare.  They  will  be  found  serv- 
iceable in  straightening  tubes,  rods  and  wire,  and  of  practical  utility 
wherever  surgical  instruments  are  used.  They  are  generally  about  5 
inches  in  length. 

Transfixion  Needles. 

These  are  occasionally  employed  in  connection  with  snares  in  order  that 
large  masses  may  be  held  in  a  favorable  position  until  the  tissues  are  sep- 
arated. They  are  useful  in  the  removal  of  such  tumors  as  can  be  drawn 
through  and  caused  to  protrude  from  the  anterior  nares. 


Figure  1713.    Jarvis'  Transfixion  Needle. 

Jarvis'  Transfixion  Needles,  as  manifest  in  figure  1713,  are  slender 
steel  needles  provided  with  delicate  handles,  by  means  of  which  they  may 
be  manipulated.  They  will  be  found  useful  when  masses  of  hypertro- 
phied  tissue  can  be  drawn  outside  of  the  nostril,  where  they  may  be  pierced 
and  held  by  the  needles,  the  loops  of  the  snare  or  cautery  being  passed 
over  the  handle  and  needle  point.  They  may  be  straight  or  half  curved, 
and  in  lengths  from  i  to  4  inches. 

Knives. 

Special  patterns  of  knives  are  usually  required  for  operations  in  the 
nares. 


gure  1714.     Ingais'  Knife. 


Ingals'  Knife,  as  delineated  in  figure  1714,  is  a  short  stout  blade  of  tri- 
angular form.  The  cutting  edge  is  usually  about  i  inch  in  extent,  termina- 
ting in  a  sharp  point. 

Allen's  Septum  Knife,  as  sketched  in  figure  1715,  is  a  short  curved  blade 
presenting  a  concave  cutting  surface  about  y±  of  an  inch  in  extent.  A  shaft 


47 


738 


NASAL    AND    N ASO-PHARYNGEAL    SURGERY. 


of  good  length  is  provided,  so  that  the  instrument  is  adapted  for  use  in  the 
deeper  portions  of  the  anterior  nares. 


Figure  1715.    Allen's  Septum  Knife. 

Seller's  Double-Edge  Knife,  as  denned  by  figure  1716,  is  of  slender  con- 
struction with  a  delicate  blade  slightly  curved  upon  the  flat  and  provided 


Figure  1716.    Seller's  Double-Edge  Knife. 

with  a  double  cutting  edge.     This  enables  the  operator  to  use  it  upon 
either  side  and  for  cutting  up  or  down. 

Curettes. 

These  dc  not  differ  materially  from  the  patterns  employed  in  the 
removal  of  tumor  masses.  As  a  rule,  only  those  with  blunt  edges  are 
used  in  this  class  of  cases. 


Bosworth's  Curette. 


Bosworth's  Curette,  as  exhibited  by  figure  1717,  has  a  long  slender  shaft 
angular  bent  and  terminating  in  a  fenestrated  blade.  The  shank  is  usually 
of  such  material  that  it  may  be  curved  to  suit  special  cases.  Generally  the 
fenestra  is  about  5  millimeters  in  breadth  by  10  in  length. 


Figure  1718.    Justis'  Curette. 

Justis'  Curette,  as  exhibited  by  figure  1718,  is  in  spoon  form  with  a  bowl 
about  5  millimeters  in  breadth  and  15  in  length.  As  usually  constructed 
it  has  a  flexible  shaft,  thus  permitting  the  instrument  to  be  curved  when 
required  for  special  cases.  It  is  provided  with  a  semi-cutting  edge. 

Cutting  Forceps. 

Forceps  for  the  removal  of  redundant  cartilaginous  tissue  are  constructed 
with  cutting  or  biting  jaws,  by  means  of  which  pieces  or  sections  may  be 
removed. 


Figure  1719.    Weir's  Cutting  Forceps. 

Weir's  Cutting  Forceps,  as  pictured  in  figure  1719,  are  short  strong  for- 
ceps about  5  inches  in  length  provided  with  double  concave  jaws,  each  with 
thin  sharp  edges.  The  cutting  surface  extends  along  one  side  and  around 


NASAL    FORCEPS.  739 

the  tip  of  each  jaw.  The  opposite  side  is  open,  that  tissues  projecting  be- 
yond the  width  of  the  forceps  blade  will  not  require  to  be  severed  in  two 
places.  The  second  cutting  would  not  in  any  way  interfere  with  the  oper- 
ation, but  it  would  require  twice  as  much  force  to  bring  the  forceps  blades 
together. 


Figure  1720.    Knight's  Nasal  Cutting    Forceps. 

Knight's  Nasal  Cutting  Forceps,  as  sketched  in  figure  1720,  comprise 
heavy  blades  and  handles,  angular  bent  on  the  edge.  The  jaws  are  oval 
and  concave,  the  outer  margins  being  of  knife-like  sharpness.  They  are 
usually  about  4  millimeters  in  length.  With  this  instrument  large  pieces 
of  tumor  masses  may  be  excised  and  removed  with  a  single  bite  of  the  in- 
strument. 


Figure  1721.    Prince's  Membrane  Forceps. 

Prince's  Gouging  Forceps,  as  depicted  in  figure  1721,  are  short,  strongly 
built  and  about  5  ^  inches  in  length.  The  blades  are  slightly  curved  upon 
the  flat.  The  jaws,  if  shorter,  might  be  called  spoon-shaped.  They  are 
concave,  \y2  inches  in  length  by  5  millimeters  in  breadth,  with  what 
might  be  called  semi-cutting  edges,  which,  although  thin,  are  not  of  knife- 
like  sharpness.  As  the  instrument  is  slightly  curved,  it  may  be  used  upon 
either  side  and  employed  for  cutting  friable  tissues  or  tearing  away  sessile 
tumors  by  avulsion.  Its  author  employs  it  as  a  substitute  for  the  snare  in 
the  removal  of  hypertos  of  the  mucous  membrane  of  the  posterior  end  of 
the  inferior  turbinated  bone. 


Figure  1722.    Myles'  Nasal  Gouging  Forceps. 

Myles'  Nasal  Gouging  Forceps,  as  shown  by  figure  1722,  consists  of  a 
fixed  blade  with  fenestrated  jaw  in  which  a  punch  is  actuated  by  means  of 
a  compound  lever  controlled  by  scissors  handles.  Although  this  instrument 


740 


NASAL    AND    N ASO-PH ARYNGEAL    SURGERY. 


is  of  strong  construction  and  possesses  considerable  force,  as  its  blades  do 
not  diverge,  it  occupies  little  space  within  the  canal.  The  fenestra  is  2  mil- 
limeters in  breadth  with  a  cutting  surface  about  7  millimeters  in  extent. 
The  under  surface  of  the  moving  jaw  is  concave,  it's  margins  presenting 
semi-cutting  edges. 


Figure  1723.    Jarvis'  Turbinate  Cutting  Forceps. 

Jarvis'  Turbinate  Cutting  Forceps,  as  displayed  in  figure  1723,  and  called 
by  its  author  a  "scissors  punch, ' '  are  short  strong  forceps  with  small  fenestra 
ted  circular  cutting  blades.  They  are  employed  in  operations  on  the  car- 
tilaginous portions  of  the  septum.  They  were  designed  for  removing  as- 
perities following  the  use  of  other  instruments.  They  possess  fine  punching 
blades,  which  greatly  facilitate  piercing  the  septum  cartilages. 


Figure  1724    Fraenkel's  Cutting  Forceps. 

Fraenkel's  Cutting  Forceps,  as  illustrated  in  figure  1724,  are  about  8  in- 
ches in  length  and  curved  on  the  edge.  Usually  they  are  manufactured  in 
pairs,  one  for  each  side.  The  cutting  edges  of  the  blades  are  parallel  with 
the  handles;  in  other  words,  they  cut  upon  the  side.  The  length  of  the  cut- 
ting surface  is  about  20  millimeters.  A  small  pin  placed  near  the  heel  of 
the  blade,  fitting  into  a  recess  upon  the  opposite  side,  holds  the  edges  in 
apposition. 


Figure  1725.    Ingals'  Bone  Cutting  Forceps. 

Ingals'  Bone-Cutting  Forceps,  as  outlined  in  figure  1725,  are  straight 
and  about  9  inches  in  length.  One  side  of  each  jaw  is  provided  with  a 
cutting  edge,  the  other  fenestrated  so  that  tissues  of  extra  width  may  pro- 


NASAL    SCISSORS. 


741 


trude  beyond  the  blades,  thus  permitting  the  closing  of  the  forceps  without 
necessitating  the  cutting  of  the  tissues  with  both  sides  of  the  jaw.  The  cut- 
ting surface  extends  not  only  along  one  side,  but  around  the  point,  thus  in- 
cluding the  beak  or  tip  of  the  instrument. 

Cohen's  Post-Nasal  Cutting  Forceps,  as  shown  by  figure  1726,  is  a  long- 
handled  forceps,  curved  upward  on  the  flat,  its  blades  terminating  in  strong 
jaws,  each  of  which  presents  on  its  inner  surface  an  oval  bowl-shaped  de- 


Figure  1796.    Cohen's  Post-Nasal  Cutting  Forceps. 

pression,  the  rim  of  which  is  of  almost  knife-like  sharpness.  The  cutting 
surface  is  usually  about  6  millimeters  in  breadth  by  12  in  length,  while  the 
entire  instrument,  including  curves,  is  about  10  inches  in  length.  This 
pattern  will  be  found  useful  in  removing  small  growths  and  fragments  of 
large  ones. 

Scissors. 

Scissors  for  use  in  the  anterior  nares  should  be  of  strong  construction 
with  short  heavy  blades. 


Figure  1727.    Ingals'  Scissors. 

Ingals'  Scissors,  as  exhibited  in  figure  1727,  have  straight  cutting  blades, 
and  the  shanks  or  handles  are  curved  downward  on  the  edge.     Usually  they 


Figure  1728.    Seller's  Scissors. 


are  about  6  inches  in  length,  round  pointed,  with  a  cutting  surface  of  nearly  2 
inches.     As  they  occupy  but  little  space,  they  are  well  adapted  for  remov- 


742 


NASAL  AND  NASO-PHARYNGEAL  SURGERY. 


ing  soft  tissues,  trimming"  the  margins  of  wounds,  etc.  Ingals  claims  great 
advantages  for  this  instrument  when  used  for  packing  the  nasal  cavity. 
Unlike  a  forceps,  it  has  no  tendency  to  pull  the  pressed-in  material  from 
place. 

Seller's  Scissors,  as  pictured  in  figure  1728,  have  long  slender  blades 
with  handles  bent  downward  on  the  edge.  They  present  a  cutting  surface 
of  i  y2  inches,  with  a  total  length  of  7  inches. 


Figure  1729.    Potter's  Scissors. 


Potter's  Scissors,  as  drawn  in  figure  1729,  are  constructed  with  straight 
blades,  but  with  shanks  sharply  bent  downward  on  the  edge.  The  blades 
are  provided  with  fine  saw  teeth.  It  is  claimed  that  the  use  of  scissors  so 
constructed  does  not  tend  to  force  the  tissues  out  from  between  the  blades, 
that  engagement  is  more  easily  secured  and  incision  more  certain. 


Figure  1730.    Ingals'  Turbinated 
Scissors. 


Ingals'  Turbinated  Scissors,  as  they  appear  in  figure  1730,  have  heavy 
short  blades,  the  handles  and  blades  being  curved  on  the  edge  throughout 
their  whole  length.  The  blades  are  short  and  thus  particularly  adapted  for 
removing  the  hypertrophied  middle  turbinates.  They  will  be  found  service- 
able where  scissors  with  longer  jaws  and  of  lighter  patterns  would  prove 
inefficient. 


Figure  1731.    Casselberry's 
Scissors. 


Casselberry's  Scissors,  as  explained  by  figure  1731,  do  not  differ  from  the 
pattern  of  Ingals  except  in  being  shorter  and  provided  with  jaws  with  saw 
teeth  of  the  same  construction  as  those  described  in  connection  with  the 
pattern  of  Potter  previously  referred  to. 


HEMOSTATIC    CLAMPS.  743 

Ingals'  Septum  Bone  Scissors,  as  portrayed  in  figure  1732,  have  forceps 
handles  with  short  straight  blades.     As  the  pivot  is  only  about  i  inch  from 


Figure  1732.    Ingals'  Septum  Bone  Scissors. 

the  tip  of  the  blade,  the  instrument  possesses  great  leverage.     The  blades 
present  a  cutting  surface  of  about  1 5  millimeters. 

Hemostatic  Clamps. 

These  consist  of  clamps  or  forceps  employed  to  control  hemorrhage  by 
direct  pressure  on  the  bleeding  vessel,  following  operations  on  the  septum. 


Figure  1733.    Jarvis'  Hemostatic  Clamp. 

Jarvis'  Hemostatic  Clamp,  as  shown  in  figure  1733,  consists  of  two  arms 
controlled  by  screw  power,  each  terminating  in  an  oval  plate,  one  fenestrated, 
the  other  solid.  These  plates  are  of  such  size  that  they  may  be  easily 
passed  into  the  nostrils.  By  placing  the  solid  plate  over  the  point  of  hem- 
orrhage and  exerting  screw  power  the  hemorrhage  may  be  controlled. 

Galvano-Cautery. 

This  is  usually  employed  in  nasal  surgery  by  means  of  points,  knives 
and  snares.  As  this  subject  is  fully  covered  in  the  chapter  devoted  to  Elec- 
tricity, no  further  mention  is  required  here.  The  various  forms  of  appli- 
ances are  illustrated  by  figures  487  to  543. 

Saws. 

These  are  usually  preferred  in  operations  upon  the  turbinated  bodies 
because  their  use  results  in  a  smooth  even  surface.  This  is  advantageous, 
because  it  is  claimed  that  projections  are  likely  to  cause  a  thickening  of  the 
tissues  by  natural  processes.  Saws  with  thin  blades  and  fine  teeth  are 
usually  selected. 

Bosworth's  Saws,  as  illustrated  by  figures  1734  and  1735,  differ  only  in 
the  shape  of  the  shank,  one  being  straight,  the  others  bent  downward  on 
the  edge  at  an  angle  of  about  135°,  one  with  the  teeth  or  cutting  edge  up, 
the  other  down.  They  are  manufactured  from  material  as  thin  as  is  pos- 
sible consistent  with  the  necessary  strength.  The  entire  length  of  the  in- 
strument is  from  9  to  10  inches,  bent  near  the  center,  the  cutting  surface 
continuing  for  about  3  inches.  The  blade  at  its  tip  is  about  fa  °f  an 


744 


NASAL    AND    NASO-PH ARYNGEAL    SURGERY. 


wide  and  about  T\  of  an  inch  wide  at  its  widest  portion.  When  properly 
made,  they  are  constructed  with  30  teeth  to  the  inch,  each  tooth  an  equilat- 
eral triangle,  there  being  no  set  or  spread  to  the  teeth.  When  the  surgeon 


Figure  1734.    Bos  worth's  Straight  Saw. 


Figure  1735.     Bosworth's  Saws,  Cutting 
Up  or  Down. 


is  limited  to  the  use  of  one  instrument,  Bosworth  recommends  the  saw  with 
the  cutting  edge  down. 


Figure  1736.     Holbrook-Curtis  Saw. 

Holbrook-Curtis  Saw,  as  described  in  figure  1736,  is  one  of  the  most 
delicate  of  this  class  of  instruments.  Its  extreme  length  is  about  7  inches, 
with  a  cutting  surface  of  about  i^  inches,  the  blade  being  delicate  and 
slightly  probe-pointed. 

It  varies  from  3  to  4  millimeters  in  width.  The  teeth  are  fine,  and  as  the 
blade  is  thickest  at  the  cutting  edge,  it  possesses  the  advantages  of  an  ordi- 
nary saw  with  "set"  teeth. 


Figure  1737.    Casselberry's  Saw. 

Casselberry's  Saw,  an  illustration  of  which  may  be  seen  in  figure  1737, 
is  a  curved  blade  with  a  concave  cutting  surface.  The  blade  has  a  uniform 
width  of  about  l/b  of  an  inch.  The  teeth  are  equilateral  triangles,  the  apex 
of  every  alternate  tooth  being  upon  the  same  side.  The  blade  is  curved 
with  the  concavity  upward.  This  is  to  conform  to  the  floor  of  the  nose. 
Its  author  claims  it  can  be  better  introduced  in  certain  cases  than  a  straight 
one.  It  is  constructed  to  cut  upon  the  "pull"  instead  of  the  "push,"  an  ob- 
vious advantage,  its  inventor  claims,  in  this  class  of  work,  because  on  the 
"push"  it  is  necessary  to  insinuate  its  elastic  end  carefully  between  the 
parts,  while  on  the  "pull"  its  passage  is  free. 


NASAL    DRILLS,   CHISELS    AND    GOUGES.  740 

Bucklin's  Saws,  as  traced  in  figure  1738,  comprise  a  solid  metallic  handle 
to  which  either  of  the  blades  shown  in  the  illustration  may  be  attached  by 


Figure  1738.    Bucklin's  Saws. 

slip  joint  and  set  screw.     The  teeth  of  the  blades  are  finely  cut,  and  the 
instrument  of  solid  and  firm  construction. 

Surgical  Drills. 

Drills,  in  the  form  of  a  common  foot-treadle  dental  drill  or  the  more 
elaborate  electrical  outfit,  now  constitute  a  necessary  appliance  in  the  office 
of  the  nasal  specialist.  The  better  form,  and  that  which  is  most  acceptable 
to  patients,  is  suspended  from  the  ceiling  and  operated  by  an  electric  motor. 
This  system,  in  a  great  measure,  overcomes  the  natural  dread  prevailing 
among  patients  when  called  upon  to  face  the  noisy,  cumbersome  and  seem- 
ingly brutal  dental  foot-engine.  With  the  former  any  desired  speed  may 
be  obtained,  and  the  work  not  only  facilitated,  but  rendered  less  painful.  A 
motor  of  one-eighth  horse  power  is  all  that  is  required,  and  it  may  be  oper- 
ated either  by  a  street  current  or  storage  cells.  It  should  be  controlled  by 
pressure  of  the  foot  or  an  electric  button.  The  necessary  drills  may  be  ob- 
tained in  various  forms.  These  may  comprise  plain  drills,  burrs,  trephines, 
and  revolving  knives,  which  are  well  illustrated  by  figures  874  to  88 1. 

Chisels. 

These  are  employed  by  some  surgeons  not  only  in  operations  where  car- 
tilaginous tissues  are  involved,  but  in  those  necessitating  the  removal  of 
bone.  They  may  be  obtained  for  use  with  either  hand  or  mallet. 


Figure  1739.    Plain  Nasal  Chisel  for  Use  with  Hand. 

The  Plain  Hand  Chisel,  which  is  shown  by  figure  1739,  has  a  straight 
chisel  blade  about  T\  of  an  inch  in  width  with  a  light  hollow  handle,  the 
whole  instrument  being  from  8  to  9  inches  in  length. 

Gouges. 

These  differ  from  chisels  only  in  being  constructed  with  a  curved 
cutting  surface.  They  are  usually  intended  for  use  with  the  hand. 

The  Seiss  Gouge,  as  made  clear  in  figure  1740,  is  bent  downward  at  an 
angle,  is  about  7  inches  in  length  and  has  a  breadth  or  cutting  surface  about 
T\  of  an  inch  wide.  The  cutting  portion  of  the  chisel  is  straight. 


746 


NASAL    AND    NASO-PH ARYNGEAL    SURGERY. 


The  Plain  Curved  Gouge,  as  may  be  seen  by  consulting  figure  1741,  is 
a  long  curved  shank  terminating  in  a  gouge-shaped  point.     The  length  of 


Figure  1740.    Seiss"  Nasal  Gouge. 


the  instrument  is  about  8  inches  with  a  cutting  surface  about 
in  width. 


of  an  inch 


Figure  1741.     Plain  Curved  Gouge. 


Hawley's  Gouge,  as  detailed  in  figure  1742,  is  constructed  for  use  with 
a  mallet.     It  consists  of  a  straight  gouge  about  4  inches  in  length  with  a 


Figure  1742.    Hawley's  Gouge. 


cutting  surface  about  ^  of  an  inch  in  width.  Near  the  proximal  end  a  handle 
is  attached  at  an  angle  of  about  120°,  by  which  the  instrument  is  held  in 
place.  It  may  be  used  with  any  of  the  ordinary  forms  of  mallets. 


Figure  1743.    Woake's  Plough. 


Figure  1744.    Woake's  Forceps,  Right  and 
Left,  for  Use  with  Plough. 

-  Woake's  Forceps,  as  shown  in  figure  1744,  are  in  bayonet  form  with 
long  serrated  jaws.  They  are  employed  for  firmly  holding  masses  of  tissue 
during  excision  by  a  forward  cutting  motion  of  the  gouge  or  plough.  In- 
cluding curves,  they  are  about  6  inches  in  length,  the  serrated  portion  ex- 
tending for  2  inches  along  the  blade.  They  are  made  in  rights  and  lefts 
for  use  on  either  side. 


NASAL    SPUDS    AND    SPATULAS. 


747 


Woake's  Plough,  as  traced  in  figure  1743,  consists  of  a  triangular  gouge 
adapted  for  use  with  the  forceps  above  referred  to.  One  point,  formed  by 
the  angle  of  the  distal  end  of  the  blade,  is  longer  than  the  other,  and  is 
rounded  so  as  not  to  injure  the  soft  tissues  when  in  use.  While  the  tissues 
are  firmly  held  in  the  forceps  jaws,  removal  is  effected  by  passing  the  gouge 
between  the  forceps  and  the  nasal  wall. 

Spuds. 

In  operations  where  removal  of  bone  is  necessary,  it  is  usually  impor- 
tant to  first  detach  the  mucous  membrane  in  flaps,  in  order  to  preserve  as 
much  of  it  as  possible.  Instruments  for  this  purpose  are  called  spuds. 


Figure  1745.    Ingals'  Spud. 


Ingals'  Spud,  as  pictured  in  figure  1745,  consists  of  a  flat  strong  handle, 
terminating  in  a  small  oval  bulb -shaped  tip,  flat  upon  one  side. 


Figure  1746.    Asche's  Spud. 

Asche's  Spud,  as  portrayed  in  figure  1746,  does  not  differ  materially 
from  many  of  the  patterns  of  periosteal  elevators  used  in  ordinary  oper- 
ations upon  bone,  excepting  in  the  use  to  which  it  is  put.  It  consists  of  a 
slender  blade  curved  on  the  flat  with  semi-cutting  edges  and  sharp  points. 
It  is  called  by  its  author  a  separator  and  is  employed  for  detaching  the 
mucous  membrane  and  periosteum  when  operations  on  the  underlying  bone 
are  necessary.  It  is  usually  about  6  inches  in  length  with  a  breadth  of  blade 
of  7  millimeters. 

Spatulas. 

These  are  employed  for  holding  mucous  flaps  in  place,  as  a  guard 
against  accidental  burning  from  the  galvano-cautery,  and  for  pressing  aside 
soft  tissues  that  obstruct  the  field  of  vision. 


Figure  1747.    Ingals'  Spatula. 

Ingals'  Spatulas,  as  sketched  in  figure  1747,  are  strips  of  thin  metal, 
wider  at  one  end  than  at  the  other,  and  bent  in  the  center  at  an  angle  of 
about  135°.  The  ends  are  oval  and  in  spatula  form.  They  are  usually  to 
be  found  in  sets  of  three,  varying  in  width  from  7  to  13  millimeters. 

Dilators  and  Tubes. 

These  are  used  to  reduce  engorgement  and  maintain  the  patency  of  the 
canal.  They  are  useful  after  operations,  to  prevent  adhesions  of  raw  oppos- 
ing surfaces. 


748 


NASAL    AND    N ASO-PH ARYNGEAL    SURGERY. 


Brown's  Nasal  Dilators,  as  sketched  in  figure  1749,  consist  of  rigid  metal- 
lic plugs,  oval  and  slightly  tapering  in  form.     They  are  usually  from  2  to 


Figure  1748.    Bishop's  Nasal  Dilator. 


Figure  1749.     Brown's  Xasal  Dilator. 


zy2  inches  in  length  and  vary  in  breadth  from  7  to  12  millimeters.     They 
may,  however,  be  obtained  in  any  desired  size. 

Bishop's  Dilators,  as  shown  in  figure  1748,  differ  from  the  pattern  of 
Brown  in  being  composed  of  soft  rubber.  Like  the  former  pattern,  they 
may  be  obtained  in  various  sizes. 


Figure  1750.    Goodwillie's  Tube. 


Figure  1751.    Myers'  Tube. 


Myers*  Tube,  as  sketched  in  figure  1751,  is  in  general  form  like  a  flat- 
tened truncated  cone  curved  on  the  edge  and  its  outer  margins  provided 
with  numerous  small  perforations.  As  they  are  of  hard  rubber,  they  serve 
to  retain  the  patency  and  general  form  of  the  canal.  They  are  manufac- 
tured in  six  sizes,  the  lumen  at  its  external  opening  being  in  the  smaller  5 
by  10,  and  in  the  larger  8  by  16  millimeters,  while  the  length  of  the  smaller 
is  about  i  inch  and  of  the  larger  about  i  ^  inches. 

Goodwillie's  Tubes,  as  depicted  in  figure  1750,  are  soft  rubber  tubes,  oval 
and  slightly  conical,  their  proximal  ends  somewhat  bulging  and  curved  down- 
ward on  the  edge.  They  are  usually  manufactured  in  three  sizes  with  a 
length  of  from  2^  to  3  inches.  This  may  be  shortened  to  suit  the  require- 
ments of  individual  cases. 


REMOVAL  OF  TUMORS. 


Polypi  and  other  forms  of  tumors  may  generally  be  removed  by  some  one 
of  the  following  instruments:  Forceps,  snares,  curettes  and  galvano-cau- 
tery.  Usually,  their  removal  is  preceded  by  an  application  of  cocaine. 
This  may  be  introduced  with  any  suitable  syringe,  the  one  illustrated  by 
figure  1700  being  often  employed. 

Removal  by  forceps  may  be  accomplished  by  avulsion,  crushing  or  mor- 
cellement. 

Avulsion  Forceps. 

The  extirpation  of  tumors  by  avulsion  requires  a  forceps  with  strong 
jaws  by  which  the  tumor  mass  may  be  grasped  and  forcibly  detached  en 
masse.  Owing  to  the  danger  of  hemorrhage  and  the  pain  caused  to  the  pa- 
tient, this  method  is  employed  only  on  small  tumors. 

Duplay's  Polypus  Forceps,  as  shown  in  figure  1752,  consist  of  long  slen- 
der blades  terminating  in  jaws  that  present  concave  inner  surfaces,  the  mar- 
gins of  which  are  transversely  serrated,  thus  providing  lateral  rows  of  fine 
and  somewhat  sharp  teeth.  The  instrument  is  well  adapted  for  operating 


REMOVAL    OF    TUMORS. 


749 


in  a  limited  space.  A  series  of  catches  is  provided,  that  the  instrument 
may  be  accommodated  to  various  thicknesses  of  tissue.  Its  length  is  about 
8  inches. 


Figure  1752.    Duplay's  Polypus  Forceps. 


Simrock's  Polypus  Forceps,  as  shown  in  figure  1754,  are  about  7  inches 
in  length,  of  light  construction  and  angular  bent  on  the  flat.     The  shanks 


Figure  1754.     Simrock's  Polypus  Forceps. 


and  jaws  are  delicate,  the  latter  about  ^  an  inch  in  extent,  doubly  concave 
with  serrated  margins  and  provided  with  small  fenestrae,  by  which  the  in- 
strument may  be  used  for  passing  ligatures,  threads,  etc. 

Crushing  Forceps. 

Tumors  of  the  nose  may  be  destroyed  by  crushing  them  between  the 
blades  of  strong  forceps.  An  ordinary  polypus  forceps  may  be  used  for  this 
purpose.  Usually,  one  with  broad  jaws  is  preferred. 


Figure  1755.    Gross'  Polypus  Forceps. 

Gross'  Polypus  Forceps,  as  illustrated  in  figure  1755,  are  one  of  the  best 
known  patterns  among  this  class  of  instruments.  They  are  of  heavy  con- 
struction, about  8  inches  in  length  and  slightly  curved  upon  the  flat.  The 
jaws  are  about  $/s  of  an  inch  in  extent,  doubly  concave,  with  serrated  mar- 
gins and  with  small  fenestrae,  the  latter  enabling  the  operator  to  use  the 
forceps  as  a  ligature  or  thread  carrier. 

Morcellement  Forceps. 

The  removal  of  tumors  by  morcellement  requires  what  is  known  as  cut- 
ting forceps.  These  are  often  called  gouging,  curette  or  biting  forceps. 


Figure  1756.     Shaffer's  Cutting  Forceps. 


750 


NASAL    AND    N ASO-PHARYNGEAL    SURGERY. 


Shaffer's  Cutting  Forceps,  as  is  apparent  in  figure  1756,  have  oval  con- 
cave cutting  jaws  with  a  contact  surface  of  6  by  9  millimeters.  They  are  of 
heavy  construction,  in  bayonet  form,  and  about  7^  inches  in  length. 


Figure  1757.    Ingals'  Cutting  Forceps. 


Ingals'  Cutting  Forceps,  as  disclosed  by  figure  1757,  are  a  delicate  pat- 
tern about  8  inches  in  length,  angular  bent  on  the  flat.  The  blades  are 
slender,  terminating  in  small  circular  cutting  surfaces  ;  in  other  words,  the 
jaws  consist  of  round  steel  loops  or  circles  having  an  internal  diameter  of 
about  3  millimeters. 


Figure  1759.    Jarvis'  Small  Spring  Punch  Forceps. 


Jarvis'  Small  Spring  Punch  Forceps,  as  illustrated  in  figure  1759,  con- 
sist of  a  spring  forceps  angular  bent  downward  on  the  flat.  The  lower 
blade  is  rigid  and  terminates  in  two  slender  rod-like  arms  that  form  second- 
ary blades.  These  terminate  in  circular  jaws,  one  of  which  when  closed 
rests  within  the  other.  The  outer  blade  is  jointed  at  the  bend  in  such  a 
manner  that  compression  and  relaxation  of  the  spring  cause  a  backward 
and  forward  movement  of  the  hinged  portion  of  the  blade.  The  latter  is 


Figure  1760.    Casselberry's  Cutting  Forceps. 

tubular  at  its  distal  end,  the  secondary  arms  previously  referred  to  being 
located  within  the  cylinder.  The  jaws,  in  their  natural  condition  with  the 
spring  relaxed,  are  self-opening,  and  are  closed  by  compression  of  the 
spring.  The  instrument  is  used  for  the  removal  of  small  myomata.  It  will 
be  found  useful  in  grasping  and  dividing  clusters  of  diminutive  polypi,  even 
when  resting  in  the  almost  inaccessible  recesses  of  the  superior  meatus. 


REMOVAL    OF    TUMORS. 


751 


As  stated  by  its  inventor,  the  device  acts  as  a  portable  searcher,  seeking  the 
embryonic  or  glistening  "Bead-like  masses  and  cutting  and  dragging  them 
from  their  basic  attachment." 

Casselberry's  Cutting  Forceps,  as  exhibited  in  figure  1760,  are  of  heavy 
construction,  with  handles  slightly  curved  downward  and  blades  short  and 
curved  upward  on  the  flat.  Like  the  patterns  previously  described,  both 
blades  are  fenestrated,  one  closing  within  the  other.  The  small  fenestra  is 
6  millimeters  in  width  by  10  in  length.  The  entire  length  of  the  forceps  is 
iy2  inches,  the  post-nasal  projection  being  i%  inches  long. 


Figure  1761.    Quinlan's  Cutting  Forceps. 

Quinlan's  Cutting  Forceps,  as  portrayed  in  figure  1761,  differ  essentially 
from  the  previously  described  patterns  in  that  the  blades  are  curved  in  bay- 
onet shape,  the  cup-shaped  jaws  forming  the  distal  arms.  The  latter  at 
their  proximal  faces  are  concave,  the  rim  or  border  portion  of  each  con- 
stituting the  cutting  edge.  These  jaws  are  6  by  io  millimeters  in  diameter 
at  their  cutting  margins  and  the  whole  forceps  is  8  inches  in  length. 


Figure  1762. 


Schultz's  Cutting  Forceps,  as  depicted   in  figure  1762,   are    constructed 


with  strong  shanks,  the  handles  curved  downward  and  blades  bent  upward 
on  the  edge  at  nearly  a  right  angle.  The  latter  terminate  in  fenestrated 
jaws  somewhat  triangular  in  form,  the  outer  or  cutting  margins  pre- 
senting an  upward  convex  surface. 


Figure  1763.    Holbrook's-Curtis'  Post-Nasal  Forceps. 

Instead  of  closing  one  within  the  other,  the  cutting  surfaces  meet  in  accu- 
rate approximation.  They  are  constructed  in  three  sizes,  the  lateral  diam- 
eter of  the  fenestrae  being  12,  15  and  18  millimeters,  respectively.  As 


LLlElilE    01- 


752  NASAL    AND    X ASO-PHARYXGEAL    SURGERY. 

will  be  seen  from  the  illustration,  this  forceps  cuts  in  an  antero-posterior 
direction. 

Holbrook's-Curtis'  Post-Nasal  Forceps,  as  exhibited  in  figure  1763,  are  of 
medium  weight  with  blades  angular  bent  upward  on  the  flat  and  handles 
slightly  bent  downward.  Both  blades  are  fenestrated  with  oval  openings, 
one  closing  slightly  within  the  other.  They  furnish  means  for  complete 
excision  of  any  included  tissues.  The  length  of  the  small  fenestrse  is  13 
millimeters  with  a  breadth  of  6  millimeters,  while  the  total  length  of  the 
forceps  in  a  direct  line  from  tip  to  handle  is  8^  inches.  The  post-nasal 
projection  of  the  forceps  blade  is  2  inches  long. 

Curettes. 

Curettes  for  operations  in  the  nares  are  usually  sharp,  some  patterns 
being  provided  with  knife-like  edges. 


Figure  1764.     Brown's  Curette. 

Brown's  Curette,  as  shown  by  figure  1764,  is  spoon-shaped,  and  in  gen- 
eral form  does  not  differ  much  from  those  generally  employed  in  operations 
upon  bone.  The  cutting  surface  is  oval  in  form  and  usually  in  two  sizes, 
•one  4,  the  other  6  millimeters  in  their  shortest  diameter. 


Figure  1765.    Shaffer's  Curette. 

Shaffer's  Curette,  as  defined  in  figure  1765,  consists  of  a  handle  usually 
•octagonal  in  shape,  and  provided  with  a  curette  at  each  end.  the  whole  instru- 
ment having  a  length  of  about  8  inches.  One  of  the  curettes  consists  of  a 
circular-shaped  bowl  with  sharp-cutting  margins,  having  a  diameter  of 
about  5  millimeters.  The  opposite  curette  is  spoon  shaped  with  oval  mar- 
gins and  slightly  curved  upon  the  flat.  It  is  about  2  millimeters  in  its 
short,  and  9  millimeters  in  its  long  diameter. 


Figure  1766.    Maier's  Curette. 


Maier's  Curette,  a  likeness  of  which  is  seen  in  figure  1766,  might  with 
propriety  be  classed  as  a  circular  knife,  for  it  furnishes  an  oval-shaped  cut- 
ting blade  of  knife-like  sharpness.  The  blade  is  mounted  on  the  end  of  a 
strong  steel  shank,  the  whole  instrument  being  8  or  9  inches  in  length. 
The  diameter  of  the  fenestra  is  usually  about  6  by  9  millimeters. 


Figure  1767.     Gottstein's  Post-Nasal  Curette. 


Gottstein's  Curette,  as  exhibited  in  figure  1767,  consists  of  a  fenestrated 
oval  blade,  the  cutting  surface  of  which  is  inclined  in  an  outward  direction, 
making  an  angle  of  about  45°  with  the  shaft.  This  position  is  secured  by 


;  0 


J  J  C 


CORRECTION    OF    DEFORMITIES. 


753 


curving  the  shank  until  the  fenestrated  portion  rests  at  nearly  a  right  angle, 
and  bending  the  upper  portion  on  the  flat.  Only  the  under  surface  of  the 
blade  presents  a  cutting  edge.  They  may  be  obtained  in  sizes  varying 
from  10  to  15  millimeters  in  the  widest  portion  of  the  fenestra. 


Figure  1768.    Pynchon's  Post-Nasal  Curette. 

Pynchon's  Post-Nasal  Curette,  as  represented  in  figure  1768,  differs 
from  the  pattern  of  Gottstein  in  that  the  fenestrated  portion  throughout  its 
entire  length  is  curved  backward  on  the  edge,  while  the  sides  are  nearly  per- 
pendicular. The  loop  is  flattened  and  flaring,  the  sides  as  well  as  the  under 
surface  being  sharpened.  This  form  furnishes  a  more  effectual  instrument 
for  the  removal  of  tumor  masses.  It  is  manufactured  in  sizes  that  vary 
from  8  to  13  millimeters  in  transverse  internal  diameter. 


Figure  1769.     Leffert's  Curette. 


Leffert's  Curette,  as  pictured  in  figure  1769,  is  similar  to  the  pattern  of 
Gottstein,  but  has  a  broader  fenestra  and  a  cutting  face  that  makes  an  angle 
of  about  60°  with  the  axis  of  the  shaft.  It  is  manufactured  in  the  same 
.sizes  as  the  pattern  of  Gottstein. 


Figure  1770.    Kirsten's  Curette. 


Kirsten's  Curette,  as  shown  in  figure  1770,  consists  in  its  essential  feat- 
ures of  a  long  oval  blade  curved  upward  on  the  flat  and  with  a  cutting  edge 
at  a  right  angle  with  the  shaft.  It  is  made  in  three  sizes  with  fenestrae 
from  55  to  65  millimeters  in  length  and  from  12  to  15  millimeters  in  breadth. 


CORRECTION  OF  DEFORMITIES 

Stenosis  caused  by  deflections  of  the  nasal  septum,  may  be  relieved  by 
excision  of  the  projecting  portions  or  by  returning  them  to  their  normal  posi- 
tion by  pressure.  The  instruments  employed  for  the  removal  of  bone  have 
been  previously  described  and  illustrated.  Instruments  for  the  correction 
of  the  deformity  by  incision  and  pressure  consist  of  punches,  scissors  for- 
ceps, splints,  etc. 

Punch  Forceps. 

These  are  employed  for  making  excisions  through  the  septum,  that  their 
deviation  may  be  the  more  easily  corrected  by  straightening  forceps  or 
clamps. 

Steele's  Septum  Punch,  which  is  shown  in  figure  1771,  is  a  short  heavy 

48 


754 


NASAL    AND    NASO-PHARYNGEAL    SURGERY. 


forceps,  one  jaw  of  which  presents  a  flat  surface  with  a  face  of  lead  or  other 
soft  material.  The  opposite  blade  is  armed  with  a  steel  punch,  the  central 
portion  of  which  consists  of  a  blade  about  n  millimeters  in  length, 
parallel  with  the  handle  of  the  instrument  and  provided  with  four  wings  or 
branches,  attached  in  pairs,  one  set  forming  an  acute,  the  other  an  ob- 


Figure  1771.    Steele's  Septum  Punch. 

tuse  angle.  The  extreme  lateral  width  of  the  incision  made  by  this  instru- 
ment is  about  6  millimeters.  As  the  flaps  cut  by  this  punch  are  all  triangu- 
lar, they  can  be  pressed  one  over  the  other. 


Figure  1772.    Jarvis'  Modification  of  Steele's  Septum  Punch. 


Jarvis'  Modification  of  Steele's  Septum  Punch,  as  described  by  figure 
1772,  differs  from  the  pattern  last  mentioned  in  that  it  consists  of  eight  steel 
blades,  each  about  4  millimeters  in  length  and  arranged  in  a  circular  or 
stellate  form.  The  extreme  diameter  of  the  row  of  circular  incisions  formed 
by  the  use  of  this  instrument  is  about  8  millimeters.  It  is  so  constructed 
that  the  blades  may  be  introduced  separately,  after  which  they  may  be 
locked  by  a  device  similar  to  that  of  an  obstetrical  forceps. 


Figure  1773.    Sajous'  Septum  Punch. 

Sajous'  Septum  Punch,  as  will  be  seen  by  referring  to  figure  1773,  con- 
sists of  a  short  heavy  forceps,  to  which  may  be  attached  blades  or  punches 
of  various  shapes  and  sizes,  all  of  which  are  shown  in  the  illustration. 
Usually  six  comprise  a  set,  which  may  be  described  as  follows : 

Straight  blade,  10  millimeters  wide;  curved  blade,  10  millimeters  wide; 
oval  blade,  8  millimeters  in  long  diameter;  Steele's  blade  (see  figure  1771), 
8  millimeters  in  length ;  heart-shaped  triangle,  length  of  longest  margin,  1 2 
millimeters,  and  ovoid  blade,  1 2  millimeters  long,  provided  with  six  short 
steel  lateral  branches.  Any  one  of  these  blades  may  be  attached  to  the 
handle  by  a  screw. 


CORRECTION    OF    DEFORMITIES. 

Septum   Scissors. 


755 


Asche's  Straight  and  Curved  Scissors,  as  exhibited  by  figures  1774  and 
1775,  differ  from  each  other  only  in  that  while  the  line  of  incision  formed 
by  the  straight  instrument  is  parallel  with  the  long  axis  of  the  handles,  in 
the  curved  pattern  it  is  at  right  angles  to  the  axis. 

The  shanks  or  portions  between  the  joint  and  the  cutting  sur- 
faces are  in  double-bow  form,  so  that  contact  of  the  blades  may  not  cause 


Asche  s  Straight  Septum  Scissors. 


Figure  1775.    Asche's  Curved  Septum  Scissors. 


pressure  on  the  cartilaginous  septum.  The  cutting  surfaces  are  curved  on 
the  edge,  the  heel  of  the  blade  coming  first  in  contact  with  the  tissues.  The 
instrument  cuts  with  a  sliding  motion,  thus  making  incision  easy. 

Straightening  Forceps. 

Forceps  for  forcibly  returning  a  deflected  septum  are  sometimes  called 
rhinoplastic  forceps.  They  consist  of  pincers  with  flat  inner  surfaces  em- 
ployed to  crush  or  refracture  the  misplaced  bones.  Their  use  may  be  fol- 
lowed by  the  introduction  of  clamps,  tubes,  solid  plugs  or  pledgets  of  fiber. 


Figure  1776.    Adams'  Septum-Straightening  Forceps. 

Adams'  Septum-Straightening  Forceps,  as  traced  in  figure  1776,  are  of 
heavy  construction  and  provided  with  wide  flat  jaws  suitable  for  compress- 
ing the  septum  without  materially  injuring  its  soft  external  covering. 


Figure  1777.    Asche's  Septum-Straightening  Forceps. 


Asche's  Septum-Straightening  Forceps,  as  depicted  in  figure  1777,  differ 
from  the  pattern  last  described  in  that  the  blades  are  not  in  contact  when 
the  instrument  is  closed.  This  feature  prevents  undue  pressure  upon  the 
enclosed  structures.  The  space  remaining  between  the  blades  to  accom- 


756 


NASAL    AND    NASO-PH ARYNGEAL    SURGERY. 


modate  the  tissues  is  usually  about  2  millimeters  in  breadth.  The  instru- 
ment is  about  8  inches  in  length  and  the  blades  are  slightly  curved  on  the 
flat. 

Septum  Splints. 

Splints  in  the  form  of  clamps,  braces,  plugs,  etc.,  are  employed  to  hold 
the  fractured  septum  in  position  until  union  ensues  by  natural  processes. 


Figure  1778.    Delstanche's  Septum  Clamp  and  Handle. 


Delstanche's  Septum  Clamp  and  Handle,  as  delineated  in  figure  1778, 
comprises  three  sets  of  clamps  in  varying  sizes,  each  set  arranged  to  move 
or  slide  upon  a  square  cross-bar.  The  blades  may  be  opened  or  closed  by 
a  handle.  The  blades  are  short,  sharply  curved  in  their  shanks  on  the  edge, 
provided  with  oval  tips  and  of  such  size  and  shape  as  to  avoid  pressure 
upon  the  full  area  of  the  septum.  The  proximal  end  of  each  clamp  is  pro- 
vided with  a  square  opening,  fitting  closely  over  the  cross-bar,  thus  en- 
abling the  operator  to  move  the  clamp  blade  from  side  to  side.  The  faces 
of  the  blades  are  arranged  to  be  covered  with  leather,  rubber  or  other  soft 
material  to  prevent  undue  injury  to  the  mucous  membrane.  The  clamps 
are  constructed  so  that  they  may  be  introduced  while  separated  to  any  de- 
sired extent.  They  may  be  closed  by  means  of  the  forceps  blades,  the  latter 
being  provided  with  large  fenestrse,  by  which  they  may  be  passed  over  the 
projecting  tips  of  the  cross-bar  and  the  blades  thus  forced  together.  Small 
projecting  hooks  are  provided  in  the  proximal  ends  of  the  clamps,  by  which 
the  latter  may  be  separated  when  so  desired.  Usually  the  blades  are  from 
10  to  14  millimeters  in  width  with  a  contact  surface  varying  from  25  to  40 
millimeters  in  length. 


Figure  1779.    Jarvis'  Clamp  Splint. 


Figure  1780.     Bishop's  Nasal  Support. 


Jarvis'  Clamp  Splint,  as  made  clear  by  figure  1779,  is  a  spring  clamp  rest- 
ing on  the  cutaneous  surfaces  of  the  alae  nasi.  The  action  of  this  clamp  when 
properly  applied  is  to  hold  the  septum  previously  made  plastic  by  punch  pro- 


ARTIFICIAL    SUPPORTS FOREIGN    BODIES.  757 

cedure,  in  the  proper  position  without  employing  a  plug  inside  the  nostrils. 
A  screw  controls  the  amount  of  pressure  of  the  splint,  for  such  it  really  is. 
When  the  shape  of  the  nose  is  such  that  the  splint  will  not  remain  in  place, 
it  may  be  fixed  by  attaching  the  back  of  a  piece  of  rubber  adhesive  plaster 
to  each  clamp  face  and  allowing  the  plaster  to  become  fixed  to  the  skin  by 
adhesion.  Goodwillie's  soft  nasal  plugs  may  be  used  with  this  splint  if 
desired. 


ARTIFICIAL  SUPPORTS. 

These  are  occasionally  required  in  cases  where  the  cartilaginous  portion 
has  been  destroyed  or  removed  by  operation  or  disease,  so  as  to  result  in 
collapse,  thus  permitting  the  tip  of  the  nose  to  fall  from  its  normal  position. 
In  such  cases,  some  form  of  support  may  be  employed  to  advantage. 

Bishop's  Support,  as  explained  by  figure  1780,  consists  of  a  plate  so 
shaped  as  to  correspond  to  the  normal  alae  nasi.  Usually  they  are  manu- 
factured from  hard  rubber,  because  they  are  less  conspicuous  than  if  con- 
structed from  a  bright  metal.  While  flesh -colored  celluloid,  so  far  as  we 
know,  has  not  yet  been  employed  we  would  consider  it  well-adapted  for 
this  purpose. 


FOREIGN  BODIES. 

These  may  usually  be  removed  with  some  one  of  the  many  ear  instru- 
ments described  for  this  purpose  on  pages  786,  78?  and  788.  Usually, 
mouse-tooth  forceps,  hooks,  snares,  screws  and  douches  are  employed.  As 
these  instruments  are  described  under  sub-headings  in  this  chapter,  further 
illustration  and  description  are  unnecessary.  The  following  special  patterns 
will  alone  be  included : 


Figure  1781.    Gross'  Ear  Hook  and  Fenestrated  Scoop. 

Gross'  Ear  Hook  and  Fenestrated  Scoop,  as  shown  in  figure  1781,  com- 
prises a  handle,  each  end  of  which  consists  of  an  instrument  for  this  purpose. 
One  is  a  slender  hook,  sharp  and  slightly  recurved,  which  may  be  passed 
along  the  side  of  the  canal  and  used  as  a  prehensor  to  dislodge  and  remove 
foreign  substances.  The  opposite  end  is  a  fenestrated  scoop  slightly 
curved  upon  the  flat.  It  may  be  used  to  advantage  in  removing  round 
firm  substances. 


Figure  1782.    Lister's  Foreign  Body  Hook. 

Lister's  Foreign  Body  Hook,  as  depicted  in  figure  1782,  consists  of  a 
slender  shank  terminating  in  a  hook  bent  at  a  right  angle,  the  angular  por- 
tion being  curved  on  the  flat.  This  curve  is  of  about  the  same  form  as  the 
wall  of  the  canal,  so  that  the  instrument  in  many  cases  may  be  passed  by 


758  NASAL    AND    NASO-PHARYNGEAL    SURGERY. 

or  around  the  foreign  substance.  Generally  the  instrument  is  small,  about 
4  inches  in  length,  the  curved  or  hooked  portion  being  about  5  millimeters 
long. 


Figure  1783.     Quire's  Curette. 


Quire's  Curette,  as  delineated  in  figure  1783,  consists  of  two  shafts,  which 
are  attached  to  the  end  of  a  bow  spring  that,  in  its  natural  tension,  maintains 
the  instrument  in  an  extended  position.  The  proximal  ends  of  these  shafts 
are  attached  to  a  small  arm  or  digit  in  such  a  manner  that  compression  of 
the  spring  forces  the  digit  to  assume  a  position  at  or  approaching  a 
right  angle  with  the  long  axis  of  the  instrument.  As  the  curette  is  of 
slender  and  delicate  construction,  it  may  frequently  be  passed  between  the 
wall  of  the  canal  and  the  occluding  substance,  after  which,  by  flexing  the 
short  arm,  it  may  be  used  as  a  prehensor  in  removing  the  foreign  body. 


EPISTAXIS. 

Plugging,  for  the  relief  of  nasal  hemorrhage,  may  be  performed  with 
many  ordinary  forms  of  instruments,  depending  on  the  material  selected. 
If  it  be  found  necessary  to  plug  the  posterior  nares,  a  soft  rubber  catheter 
may  be  passed  through  into  the  pharynx,  where  it  may  be  grasped  with  a 
forceps,  the  end  drawn  from  the  mouth  and  used  when  withdrawn  to  convey 
a  cord  that  may  extend  from  the  mouth  to  the  anterior  nares.  The  neces- 
sary tamponing  material  may  thus  be  drawn  into  place.  Instead  of  a  cath- 
eter, special  instruments  called  canulas  have  been  constructed. 


Figure  17&1.    Bellocq's  Canula. 

Bellocq's  Canula,  as  illustrated  in  figure  1784,  is  a  metallic  tube,  slightly 
curved  and  containing  a  steel  circular  spring.  The  distal  end  of  the  spring 
is  provided  with  a  perforated  knob,  by  means  of  which  a  cord  or  thread 
may  be  attached  to  the  instrument.  The  spring  is  so  constructed  that,  after 
the  canula  has  been  passed  until  the  pointrests  within  the  pharynx,  by  press- 
ing the  spring  forward,  the  latter,  when  projected,  should  curve  or  curl 
forward  into  the  mouth,  whence  it  may  be  easily  directed  to  the  lips.  The 
arrangement  of  spring  and  tube  is  such  that  they  telescope  within  the  can- 
ula, thus  presenting  a  compact  instrument  for  transportation.  In  the 
absence  of  this  instrument,  a  curved  metallic  male  catheter  may  often  be 
successfully  used. 

The  Soft  Rubber  Tampon,  shown  in  figure  1785,  was  first  manufactured 
for  use  with  the  author's  surgical  pump,  described  on  page  203.  It  may, 
however,  be  dilated  with  any  form  of  forcing  bulb  or  compressed  air  appar- 


TAPPING    OF    THE    ANTRUM. 


759 


atus.  To  avoid  over-distension  and  bursting,  a  piece  of  pure  gum  tubing 
with  moderately  thin  walls  should  be  used  in  connecting  the  tampon  with 
the  air-forcing  instrument.  The  tampon  consists  of  a  soft  rubber  catheter, 


Figure  1785.    Soft  Rubber  Tampon. 

the  post-nasal  end  of  which  is  covered  with  an  inflatable  bulb  of  a  size 
sufficient,  when  dilated,  to  fill  any  portion  of  the  nasal  space.  If  consider- 
able pressure  is  required,  the  rubber  bag  may  be  surrounded  by  a  cloth  sack 
of  such  a  size  that  bursting  by  overpressure  may  be  prevented. 


TAPPING  OF  THE  ANTRUM. 

Diseased  conditions  of  the  antrum  of  Highmore  may  require  the  opening 
of  the  cavity  and  the  insertion  of  a  drainage  tube.  The  instruments  em- 
ployed for  this  purpose  may  consist  of : 

Tongue  depressor,  figures  1440  to  1445. 

Knife,  figures  550  to  597. 

Trephine  or  drill,  figures  870  to  880. 

Trocar,  figures  382  to  386. 

Drainage  tube. 

Injection  syringe. 

Diagnostic  lamp. 

Ingals'  Lamp,  for  illuminating  the  antrum  of  Highmore,  as  outlined  in 
figure  1787,  is  a  3-candle  power  electric  lamp  that  may  be  used  in  connec- 
tion with  a  current  of  from  5  to  8  volts.  It  will  be  found  valuable  in  diag- 
nosing empyema.  When  in  use,  it  is  attached  to  some  form  of  tongue 
depressor. 

Drainage  Tubes. 

Drainage  tubes  for  use  in  the  antrum  may  be  made  from  silver,  rubber 
or  other  material.  Usually,  they  are  about  ^  of  an  inch  in  length 


Figure  1786.    Ingals'  Soft  Rubber  Antrum 
Tube. 


Figure  1787.    Ingals'  Lamp,  for  Trans-Illumina- 
tion of  the  Antrum. 


Figure  1788.    Talbot's  Antrum  Tube. 


and  provided  with  a  collar,  flange  or  other  means  whereby  they  are 
prevented  from  slipping  into  the  cavity.  They  are  employed  to  furnish 
drainage  and  maintain  the  patency  of  the  opening. 


760 


NASAL    AND    X  ASO-PHARYNGEAL    SURGERY. 


Ingals'  Soft  Rubber  Antrum  Tube,  as  drawn  in  figure  1786,  is  a  cylinder 
of  soft  rubber  provided  with  a  flange  at  each  end,  by  means  of  which,  after 
introduction,  it  will  remain  in  position.  Usually  these  tubes  are  about  6 
millimeters  in  diameter  and  from  19  to  35  millimeters  in  length.  For  intro- 
duction, the  distal  end  is  compressed  within  the  section  of  a  gelatine  capsule. 
After  the  tube  is  in  place  the  covering  capsule  may  be  removed  by  a  probe 

Talbot's  Antrum  Tube,  as  portrayed  in  figure  1788,  consists  of  a  small 
cylinder  attached  at  its  base  to  a  small  perforated  disc.  As  they  are  manu- 
factured of  hard  rubber,  curves  and  other  necessary  changes  may  be  made 
by  immersion  in  hot  water.  After  the  opening  is  prepared,  the  tube  cut  to 
the  proper  length  and  the  disc  trimmed  to  properly  fit  the  space  it  is  to 
occupy,  the  tube  may  be  heated  and  while  soft  fitted  to  its  place,  thus  secur- 
ing perfect  adjustment. 


Figure  1789.    Talbot's  Antrum  Drill. 

Talbot's  Antrum  Drill,  as  set  forth  in  figure  1789,  consists  of  a  handle 
with  an  adjustable  socket  in  which  a  drill  of  any  form  may  be  secured  by 
means  of  a  set  screw.  Two  patterns  accompany  each  instrument,  one  plain 
for  drilling  through  the  alveolar  process,  and  the  second,  shorter,  for  drill- 
ing through  the  outer  plate  of  bone,  a  shoulder  or  enlargement  preventing 
the  passage  of  the  drill  into  the  antrum. 

Syringes. 

These  are  frequently  required  for  cleansing  the  antrum  cavity.  They 
may  be  of  any  desired  size,  provided  the  needle  or  pipe  has  blunt  points 
and  is  of  a  diameter  small  enough  to  pass  into  or  through  the  antrum  per- 
foration. 


Figure  1790.    Ariel's  Syringe. 


Anel's  Syringe,  as  drawn  in  figure  1790,  does  not  differ  from  the  instru- 
ment employed  for  injecting  the  lachrymal  canal.  It  may  be  obtained  with 
needles  of  any  desired  size  or  length,  and  either  blunt  or  sharp-pointed. 


CHAPTER  XXIX. 


AURAL  SURGERY. 

The  various  instruments  employed  in  operations  on  the  ear  may  be  clas- 
sified as  those  for  examinations,  operations  on  the  mastoid,  removal  of  ex- 
ostoses,  extraction  of  foreign  bodies,  artificial  perforation  of  membrana 
tympani  and  allied  operations,  middle  ear  operations,  and  to  assist  hearing. 


EXAMINATIONS. 

Examinations  of  the  ear  require  the  following: 
For  the  external  auditory  canal: 

Illuminating  apparatus. 

Specula  for  straightening  canal. 

Massage  otoscope  for  ascertaining  mobility  of  membrana  tympani  and 
ossicles. 

Syringe  for  softening  and  washing  out  secretions  or  foreign  matter  and 
obstructive  bodies. 

Scoops  for  removing  cerumen,  semi-solids,  etc. 

Hooks  for  removing  foreign  bodies. 

Forceps  for  removing  epidermal  scales  and  particles  in  the  deeper  parts, 
of  the  canal. 

Cotton  carrier  for  removing  purulent  matter,  fluids,  etc. 
For  ascertaining  the  permeability  of  the  Eustachian  tube: 

Air  compressing  apparatus,  see  figures  1473  to  1483. 

Politzer  bag. 

Eustachian  catheter. 

Diagnostic  tube. 
For  intra-tympanic  otoscopy: 

Magnifying  lens 

Middle  ear  mirror. 
For  cases  of  deafness: 

Acoumeter  for  measuring  hearing  acuity. 

Tuning  forks  for  differential  diagnosis  between  diseases  of  the  middle 
and  internal  ear. 

Gallon's  whistle. 
For  determining  shape  and  extent  of  polypi  and  position  of  pedicles* 

Probes. 

Illuminating  Apparatus. 

Light  for  illuminating  purposes  may  be  diffused  daylight,  sunlight  or 
artificial  light,  all  of  which  require  the  use  of  a  reflector  to  concentrate  and 
focus  the  collected  rays.  As  the  subject  of  light,  condensers  and  reflectors 
has  been  fully  discussed  in  connection  with  figures  1446  to  1467,  no  extended 
reference  is  necessary  here.  While  diffused  daylight  and  sunlight  reveal 

761 


762  AURAL    SURGERY. 

colors,  shades  and  conditions  in  natural  tints,  there  are  many  days  when 
they  can  not  be  utilized.  The  result  is  a  dependence  on  artificial  light,  the 
various  mechanisms  for  which  are  fully  described  on  page  614. 

Reflectors  do  not  differ  from  those  shown  on  page  622,  excepting  that 
they  may  be  of  shorter  focus. 


Figure  1791.    Ear  Reflector  with  Handle. 

The  Ear  Reflector,  exhibited  in  figure  1791,  while  constructed  for  use 
with  a  handle  is  usually  supplied  with  a  post  and  ball  by  which  a  head-band 
may  be  attached.  Usually  they  are  2^  inches  in  diameter,  although  smaller 
and  larger  ones  are  preferred  by  some  operators.  They  vary  in  focus  from  3 
to  6  inches.  Specialists,  however,  generally  employ  reflectors  and  head- 
bands of  the  regular  patterns,  such  as  are  described  on  page  622,  selecting 
those  with  a  focus  of  12  to  14  inches. 

Specula. 

Specula  for  use  in  the  ear  are  short  funnel-shaped  tubes  that  may  be 
either  tubular  or  bi-valve,  the  former  being  preferred  by  surgeons  generally. 
Bi-valve  speculums  for  this  purpose,  particularly  those  of  the  Kramer  type, 
are  objectionable,  because  they  require  the  use  of  one  hand  to  hold  them  in 
place.  The  blades,  if  small  enough  for  use  in  a  narrow  canal,  are  not  broad 
enough  for  an  opening  of  large  size,  so  that  operators,  as  a  rule,  after  intro- 
duction press  tightly  upon  the  handles,  thus  attempting  dilatation  to  obtain 
all  possible  space  within  the  speculum.  This  has  caused  instrument  makers 
to  construct  them  so  heavily  and  with  such  thick  blades  as  to  unfit  them  for 
the  purpose  originally  designed. 

Tubular  specula  are  manufactured  from  metal,  rubber  and  glass,  the 
latter  now  being  seldom  employed.  When  of  metal,  brass  polished  and 
nickel-plated  is  preferable.  Silver  tarnishes  easily,  particularly  when 
brought  in  contact  with  soft  rubber,  as  is  frequently  the  case  in  storing  and 
carrying  instruments.  Aluminum  is  not  satisfactory,  for,  as  shown  on 
page  15,  this  metal  is  seldom  employed  for  surgical  purposes.  Those 
plated  with  nickel  may  be  made  light  and  are  easily  kept  bright  and  clean. 
Some  authorities  claim  that  hard  rubber  forms  the  ideal  material.  This 
substance  for  use  in  the  construction  of  ear  specula  was  first  introduced  by 
Politzer,  who  claimed  that  the  black  surface  rendered  the  appearance  of 
the  membrane  more  distinct  by  contrast;  that  the  illumination  was  clearer; 
that  they  were  lighter  and  did  not  offer  the  chilly  sensation  afforded  by 
unwarmed  metallic  instruments.  The  advantage  of  the  dark  internal  sur- 
face of  ear  specula  has  been  recognized  by  operators  for  years,  as  many  pat- 
terns of  silver  specula  were  blackened  by  the  application  of  lacquer  or  simi- 
lar coatings,  so  as  to  present  a  dead  black  appearance. 

Long  specula  are  dangerous  instruments  in  the  hands  of  inexperienced 
practitioners,  and  even  among  experts,  short  patterns  are  generally  preferred. 


EXAMINATIONS. 


763 


Kramer's  Speculum,  as  set  forth  in  figure  1792,  represents  the  standard 
bi-valve  forceps-handled  ear  speculum.  When  closed,  the  blades  are  in 
form  like  a  conical  tube  split  into  halves  through  its  long  axis,  each  half 
mounted  upon  one  end  of  a  forceps  blade.  The  blades  are  kept  closed  by 


Figure  1792.    Kramer's  Speculum. 


Figure  1793.    Bonafont's  Speculum. 


a  spring,  but  may  be  opened  to  any  desired  extent  by  pressure  on  the  handles. 
When  properly  constructed,  the  blades  are  thin,  about  i^  inches  in 
length,  4  millimeters  broad  at  their  tips  with  an  internal  diameter  of  about 
12  millimeters  at  the  base.  In  selecting  a  speculum  the  physician  should 
accept  only  one  which  has  thin  well-shaped  blades. 

Bonafont's  Bi-Valve  Speculum,  as  explained  by  figure  1793,  consists  of 
two  trough-shaped  blades  united  by  wing-like  projections  at  their  outer 
margin,  and  so  adjusted  that  they  may  be  opened  and  closed  by  a  screw 
device.  When  closed,  they  form  a  conical  instrument  that  may  be  expanded 
at  the  tip  to  any  desired  width. 

Wandless'  Bi-Valve  Speculum,  as  detailed  in  figure  1794,  constitutes  one 
of  the  simplest  and  most  practical  instruments  of  this  class.  It  closely 
resembles  the  pattern  of  Bonafont,  but  is  constructed  without  the  screw 
device.  The  blades  are  more  delicate  and  slender,  the  instrument  is  lighter 
and  has  a  separable  lock  by  which  the  blades  may  be  detached  for  cleansing. 

Tubular  Ear  Specula  are  conical  or  funnel-shaped  with  round  or  oval 
tips.  Both  of  the  latter  forms  are  recommended  by  good  authorities. 
Usually  they  may  be  procured  in  sets  of  four,  the  internal  diameter  at  the 
small  end  being  3,  4^,  6  and  7*4  millimeters,  respectively,  in  the  round 
patterns,  and  the  oval  ones  of  corresponding  sizes.  In  length  they  may  vary 
from  29  to  40  millimeters,  all  having  walls  as  thin  as  is  consistent  with  the 
slight  stability  required.  Some  are  constructed  with  flaring  and  others  with 
straight  sides.  The  rim  or  margin  forming  the  base  of  each  speculum 
should  be  milled  or  indented  with  fine  notches,  that  a  better  grasping  surface 
may  be  furnished.  Metal  specula  should  be  warmed  before  introduction, 
as  the  chilly  sensation  otherwise  caused  is  disagreeable  to  many  patients. 


TRUAXGREENE8CO. 
Figure  1794.    Wandless'  Speculum. 


Figure  1795.    Wilde's  Specula. 


Wilde's  Specula,  as  portrayed  in  figure  1795, are  plain  truncated  cones 
of  metal  or  hard  rubber.  In  sizes  and  general  construction  they  comply 
with  the  requirements  before  mentioned. 

Gruber's  Specula,  as  may  be  seen  by  consulting  figure  1796,  differ  from 


764 


AURAL    SURGERY. 


the  pattern  of  Politzer,  in  that  they  are  oval.  Their  author  claims  this 
shape  to  be  an  advantage  because  they  conform  more  closely  to  the  shape 
of  the  normal  canal  into  which  they  are  to  fit.  This  claimed  advantage  is 
denied  by  others  on  the  ground  that  the  instrument  can  not  be  rotated  and 


OO  o 


Figure  1796.    Gruber's  Specula. 


Figure  1797.     Politzer's  Specula. 


that  rotation  facilitates  introduction.    Like  the  patterns  previously  referred 
to,  they  can  be  obtained  in  metal  or  hard  rubber. 

Politzer's  Specula,  as  portrayed  in  figure  1797,  are  of  hard  rubber  with 
flaring  bell-shaped  mouths.  They  are  manufactured  in  four  sizes,  with 
measurements  as  before  stated. 

Otoscopes. 

Specula  with  reflectors  or  magnifying  lenses  attached,  are  usually  called 
otoscopes.  As  a  rule,  they  are  serviceable  rather  to  the  instrument  maker 
and  salesman  than  to  the  practitioner,  as  they  are  not  generally  considered 
of  value  for  scientific  use.  At  best  they  are  suitable  only  for  diagnostic  pur- 
poses, and  even  then  the  surgeon  will  do  better  with  a  reflector,  lens  and 
tubular  speculum,  for  with  these  instruments  separate,  he  can  form  such 
combinations  as  the  exigencies  of  the  individual  case  may  demand. 


Figure  1798.    Brunton's  Otoscope. 


Figure  1799.    Siegel's  Pneumatic 
Otoscope. 


Brunton's  Otoscope,  as  will  be  seen  by  referring  to  figure  1798,  consists 
of  a  cylindrical  body  or  tube  about  2^  inches  in  length  by  ^f  or  "/%  of  an  inch  in 
diameter,  in  the  proximal  end  of  which  is  located  a  magnifying  lens,  while 
to  the  distal  extremity,  tubular  ear  specula  of  various  sizes  may  be  attached. 
Near  the  center  of  the  tube  a  perforated  mirror,  placed  at  an  angle  of  45°, 
reflects  such  rays  of  light  as  are  collected  and  concentrated  by  a  bell-shaped 
projection  connected  by  a  side  opening  with  the  interior  of  the  tube. 

The  magnifying  lens,  the  perforation  in  the  mirror  and  the  opening  in 
the  tip  of  the  ear  speculum,  are  all  directly  in  the  long  axis  of  the  instru- 


EXAMINATIONS. 


765 


ment  and  therefore  in  line  with  each  other.     The  magnifying  lens  must 
focus  at  the  speculum  tip. 

Three  specula  are  provided,  of  varying  sizes.  The  instrument  may  be 
used  with  natural  or  artificial  light.  One  has  been  constructed  with  an  elec- 
tric light  placed  in  the  bell-shaped  side  extension.  Owing  to  the  fact  that 
the  instrument  is  complicated  and  useful  only  for  diagnostic  purposes,  it 
commands  but  a  limited  sale. 

Massage  Otoscopes. 

Pneumatic  or  massage  otoscopes  practically  consist  of  a  funnel-shaped 
tip,  the  larger  or  proximal  end  extended  in  a  cylindrical  form.  At  some 
point  within  the  cylinder  a  glass  window  is  placed,  usually  at  an  angle  with 
the  tube  and  so  constructed  that  it  forms  an  air-tight  joint.  A  side  opening 
is  provided,  by  means  of  which  an  exhaust  force  may  be  applied,  so  that 
when  the  distal  end  of  the  tube  is  closed,  a  vacuum,  may  be  produced  in  the 
instrument.  Such  an  air-tight  joint  may  be  secured  within  the  external 
meatus  by  crowding  the  point  of  the  speculum  into  the  lumen  of  a  short 
piece  of  pure  gum  tubing  and  then  firmly  pressing  the  apparatus  into  the 
canal.  By  rarifying  and  condensing  the  air  within  the  cylinder,  the  degree 
of  mobility  possessed  by  the  membrana  tympani  and  ossicles  may  be  deter- 
mined, adhesions  located,  etc. 

The  mirror  is  placed  at  an  oblique  angle  to  avoid  the  disturbing  effect 
of  reflected  light  rays.  In  some  patterns  the  cylinder  contains  a  magnify- 
ing lens  or  one  calculated  to  correct  any  sight  defect  possessed  by  the 
surgeon. 

The  means  employed  for  producing  a  movement  of  the  contained  air 
may  be  of  many  kinds.  Some  require  the  breathing  apparatus  of  the  sur- 
geon, others  a  piston  pump  or  a  rubber  bulb,  the  former  being  generally  pre- 
ferred. They  are  used  both  for  treatment  by  massage  and  for  diagnostic 
purposes. 

Siegel's  Massage  Otoscope,  as  portrayed  by  figure  1799,  is  a  short,  hard 
rubber  cylinder,  one  end  of  which  is  closed  by  a  glass  window  obliquely 


Figure  1800.     Bishop's  Massage  Otoscope. 


placed,  while  to  the  other  a  conical  ear  speculum  is  attached  by  a  screw  device 
with  suitable  packing.  Three  specula  with  apertures  of  4,  5  and  6  mil- 
limeters accompany  the  instrument.  A  soft  rubber  tube  about  12  inches  in 
length  connects  with  a  mouth-piece,  by  which  the  necessary  vacuum  or  air 
pressure  may  be  obtained. 


766 


AURAL    SURGERY. 


Bishop's  Massage  Otoscope,  as  it  appears  in  figure  1800,  combines  the 
reflecting  and  magnifying  principles  of  the  Brunton  otoscope  with  the  pneu- 
matic construction  of  the  Siegel  pattern.  It  consists  of  a  pneumatic 
cylinder  terminating  in  a  funnel-shaped  speculum,  the  cylinder  in  the  rear  of 
the  partition  glass  containing  a  perforated  reflecting  concave  mirror  and  a 
magnifying  lens.  To  the  chambered  section  of  the  cylinder  a  small  piston 
syringe  is  attached  by  a  side  opening  and  a  rubber  tube.  The  syringe  is 
so  constructed  that  it  can  be  held  and  operated  with  one  hand.  The  appa- 
ratus possesses  an  additional  advantage  in  being  supplied  with  a  reflector,  so 
that  the  use  of  a  head-mirror  is  not  necessary. 

Syringes. 

Syringes  are  adapted  for  the  removal  by  softening  and  irrigation  of 
large  masses  of  cerumen,  epidermal  scales  or  other  detritus  which  lie  upon 
or  obstruct  a  view  of  the  membrane.  They  may  be  of  brass,  glass  or  hard 
rubber. 

The  small  glass  syringes  called  ear  syringes  commonly  found  in  drug- 
stores are  mere  playthings  and  can  not  be  used  for  surgical  purposes.  Con- 
tinuous-flow syringes,  particularly  of  the  fountain  type,  are  recommended 
by  many  authors. 


Figure  1801.    Hard  Rubber  Syringe. 

The  Hard  Rubber  Syringe,  shown  in  figure  1801,  is  of  the  ordinary 
pattern.  They  may  be  procured  in  2,  3  and  4  ounce  sizes.  They  are  pro- 
vided with  a  single  conical  tip. 


Figure  1802.    Soft  Rubber  Ear  Syringe.  Figure  1803.    Allport's  Ear  Syringe. 

The  Soft  Rubber  Ear  Syringe,  presented  in  figure  1802,  consists  of  a 
small  spherical  bulb  provided  with  an  elastic  tip,  the  whole  being  molded 
from  a  single  piece  of  rubber.  The  syringe  may  be  filled  by  compressing 
the  bulb  and  immersing  the  tip  in  fluid.  By  thumb  pressure,  a  gentle  or 


Figure  1804.    Pomeroy's  Ear  Syringe. 

forcible  stream  may  be  projected,  as  desired.  The  instrument  is  well 
adapted  for  purposes  of  auto-irrigation,  not  only  because  it  is  provided  with 
a  soft  and  elastic  tip,  but  because  it  is  sold  at  a  low  price. 


EXAMINATIONS. 


767 


Allport's  Syringe,  as  depicted  in  figure  1803,  is  a  soft  rubber  bulb  to 
which  is  attached  a  metal  shaft  about  2  inches  in  length,  provided  with  a 
shield  and  terminating  in  an  acorn-shaped  tip  of  such  size  and  shape  as  will 
readily  fit  the  external  opening  of  the  canal.  As  the  bulb  is  large,  there  is 
no  danger  of  injuring  the  membrane,  for  only  a  firm  external  contact  can  be 
made. 

Pomeroy's  Ear  Syringe,  as  indicated  in  figure  1804,  is  a  metallic  syringe 
of  about  3-ounce  capacity,  to  the  base  of  which  finger  rings  are  attached. 
These,  with  the  ring  forming  the  projecting  end  of  the  piston,  furnish  a 
good  grasp,  by  means  of  which  the  syringe  may  be  held  and  operated.  A 
metallic  disc  with  an  outer  concave  surface  prevents  the  splashing  of  the 
return  current  on  either  the  instrument  or  operator.  Usually,  they  are  pro- 
vided with  two  tips,  one  long  and  slender,  the  other  short  and  quite  conical. 


Figure  1805.    Blake's  Middle  Ear  Syringe. 

Blake's  Middle  Ear  Syringe,  as  displayed  in  figure  1805,  consists  of  a 
metallic  or  hard  rubber  cylinder  with  wings  or  projections  to  enable  the 
operator  to  secure  a  good  grasp.  Two  slender  flexible  tubes,  one  bent  at 
an  angle  with  the  shaft  of  the  instrument,  the  other  doubly  curved,  enable 
the  operator  to  reach  almost  any  desired  point  in  the  middle  ear. 

Ear  Spouts. 


Figure  1806.    Arnold's  Douche  Basin. 


Figure  1807.    Hosmer's  Ear  Funnel. 


Ear  spouts  or  basins,  while  not  necessary,  are  convenient,  particularly 
for  examinations  and  office  practice.  They  serve  to  hold  or  conduct  to  a 
receptacle  any  fluids  escaping  from  the  ear. 


768 


AURAL    SURGERY. 


Arnold's  Douche  Basin,  as  represented  in  figure  1806,  consists  of  a  small 
metallic  receptacle  with  oval  front  and  flat  back,  the  latter  with  a  flange  ex- 
tension provided  with  a  fenestra  that  will  fit  over  the  auricle.  A  handle 
is  attached  to  the  base  of  the  instrument  by  means  of  which  it  may  be  car- 
ried or  held  by  patient  or  assistant.  Usually  they  are  about  2^  inches  in 
diameter  and  2  inches  deep. 


Figure  1808.    Spring-Band  Ear  Spout. 


Figure  1809.    Hosmer's  Ear  Spout. 


The  Spring-Band  Ear  Spout,  exhibited  by  figure  1808,  consists  of  a  spout 
and  fenestrated  ear-piece  attached  to  a  metal  band,  the  latter  designed  to 
pass  over  the  head.  By  this  arrangement  a  self-retaining  apparatus  is  pro- 
vided, the  spout  being  of  sufficient  length  and  breadth  to  conduct  any  escap- 
ing fluid  into  a  bowl  or  other  receptacle. 

Hosmer's  Plain  Ear  Spout,  as  shown  in  figure  1809,  is  a  plain  metallic 
spout,  the  sides  of  which  are  connected  at  the  base  by  a  long  wire  loop  of 
sufficient  length  to  pass  over  the  upper  margin  of  the  auricle,  and  by  means 
of  which  the  apparatus  is  held  in  place. 

Hosmer's  Ear  Funnel,  as  illustrated  by  figure  1807,  is  a  funnel-shaped 
receptacle  provided  with  a  wire  loop,  by  means  of  which  it  may  be  sus- 
pended from  the  ear  in  the  same  manner  as  the  ear  spout  last  referred  to. 
The  lower  opening  in  the  funnel  is  provided  with  an  acorn-shaped  tip,  to 
which  a  rubber  hose  may  be  attached,  the  latter  leading  to  any  convenient 
receptacle. 

Spoons. 

Spoons  (sometimes  called  scoops  or  curettes)  are  adapted  for  the  re- 
moval of  small  masses  of  semi-solids,  particularly  those  attached  to  the 
meatus  walls.  They  may  be  made  of  metal  or  hard  rubber.  The  former, 
owing  to  its  strength,  may  be  constructed  with  a  thinner  wall,  and  is,  there- 
fore, to  be  preferred.  Like  all  instruments  of  this  class,  they  should  be 
used  in  the  ear  cautiously  and  in  a  good  light. 


Figure  1810.    Politzer's  Ear  Spoon. 

Politzer's  Ear  Spoon,  as  shown  in  figure  1810,  is  a  hard  rubber  shaft 
doubly  curved  and  each  end  finished  in  a  spoon-like  form.  Usually  the  in- 
struments are  about  5%  inches  in  length,  the  smaller  spoon  being  3  and 
the  larger  4  millimeters  in  width. 


Figure  1811.     Hotz's  Steel  Spoon. 

Hotz's  Steel  Spoon,  as  illustrated  in  figure  1811,  is  a  slender  shank  ter- 
minating in  a  small  spoon -shaped  bowl  about  3  millimeters  in  width.  The 
entire  instrument  is  about  6  inches  in  length.  It  is  quite  slender  and  deli- 
cate and  will  be  found  available  in  cases  where  space  is  limited. 


EXAMINATIONS. 


769 


Cerumen  Forceps. 

Forceps  with  specially  constructed  jaws  are  required  for  removing  small 
particles  of  cerumen,  detached  epidermal  scales,  portions  of  membranes 
and  particles  lying  deep  within  the  canal 


Figure  1813.     Bacon's  Curette  Forceps. 

Bacon's  Curette  Forceps,  as  shown  in  figure  1813,  consists  of  a  scissors- 
handled  instrument  bent  near  its  center  at  an  angle  of  about  50°,  the  two 
blades  terminating  in  small  slender  loops  or  rings,  each  about  4  millimeters 
in  external  diameter.  The  instrument  is  particularly  recommended  for  the 
removal  of  material  that  withstands  the  action  of  a  syringe. 


Politzer's  Spoon  Forceps. 


Politzer's  Spoon  Forceps,  as  portrayed  in  figure  1814,  are  of  the  spring 
type,  the  shanks  being  bent  at  an  angle  of  about  45  °.  The  blades  are  slen- 
der, each  terminating  in  a  long  narrow  spoon-shaped  jaw  with  finely-ser- 
rated edges.  As  the  extreme  width  is  less  than  3  millimeters,  they  can  be 
used  through  a  tubular  speculum  of  the  smallest  size. 

As  the  blades  are  constructed  so  that  they  will  cross  or  pass  by  each 
other,  a  larger  grasping  field  is  secured.  This  is  an  advantage  where  space 
is  limited  as  in  a  small  speculum. 


Figure  1815.    Sexton's  Ear  Forceps. 


Sexton's  Ear  Forceps,  as  explained  by  figure  1815,  have  plain  spring 
handles,  delicate  blades  and  mouse-toothed  jaws.  Being  angular  bent  on 
edge  the  hand  does  not  obstruct  the  field  of  vision  when  the  forceps  are  in 
use.  Like  the  pattern  previously  referred  to,  they  may  be  employed  to  ad- 
vantage in  removing  small  particles  from  the  lower  portion  of  the  canal. 

Cotton  Carriers. 

These  are  employed  for  wiping  dry  any  surfaces  requiring  ex- 
amination or  cleansing.  They  are  useful  for  freeing  the  ear  from  residual 
injections,  fatty  matter  and  all  forms  of  liquid  discharges.  They  are  con- 


770        •  AURAL    SURGERY. 

structed  from  an  ordinary  wire  rod  or  may  be  of  the  forceps  type.  If  of 
the  former  they  should  be  so  shaped  that  absorbent  cotton  may  be  wound 
upon  them  in  such  a  manner  that  it  will  not  easily  be  detached  from  the 
instrument. 


Figure  1816.    Bishop's  Cotton  Carrier. 

Bishop's  Cotton  Carrier,  as  illustrated  by  figure  1816,  is  a  slender  rod  of 
gradual  diminishing  diameter,  about  4  inches  in  length,  the  handle  portion 
roughened  to  admit  of  a  good  grasp,  and  the  point  square  or  roughened,  that 
it  may  be  employed  to  engage  the  fibers  of  cotton  when  twisting  it  into  a 
mass. 


Figure  1817.    Buck's  Cotton  Carrier. 

Buck's  Cotton  Carrier,  as  pictured  in  figure  1817,  differs  from  the  pat- 
tern last  described  in  being  provided  with  a  larger  handle,  the  whole  form- 
ing an  instrument  about  6  inches  in  length. 

Politzer's  Bag-. 

The  successful  application  of  the  principle  involved  in  the  use  of  this  bag 
has  rendered  the  name  of  Politzer  a  household  word,  or  rather  a  trade  term, 
among  physicians  and  instrument  dealers  throughout  the  world. 

The  bag  devised  by  him  is  made  from  soft  rubber,  pyriform  in  shape, 
the  apex  terminating  in  a  hard  rubber  connector  to  which  may  be  attached 
either  a  conical  tip,  suitable  for  insertion  in  the  base  of  an  Eustachian  cath- 
eter, or  a  soft  rubber  tube,  in  the  distal  end  of  which  may  be  inserted  a 
nozzle  suitable  for  introduction  into  the  nasal  meatus.  The  soft  rubber 


Figure  1818.    Politzer's  Air  Bag. 

tube  is  employed  in  some  cases  as  a  connector  between  the  bag  and  nozzle, 
that  the  firm  contact  of  the  stiff  neck  and  nozzle  may  not  injure  the  nasal 
mucous  membrane. 

Politzer's  Air  Bag  may  be  obtained  with  a  valve  inserted  in  the  wall  that 
it  may  be  refilled  with  air  without  disconnecting  the  instrument.  Experi- 
ence, however,  has  demonstrated  that  a  valve  soon  gets  out  of  order  or  that 
the  fitting  of  the  valve  around  the  wall  opening  becomes  torn  or  otherwise 
mutilated,  for  which  reason  they  are  not  advised.  The  size  recommended 
by  the  inventor  is  from  10  to  12  ounces.  Those  usually  sold  in  this  country 
vary  from  6  to  8  ounces,  while  they  may  be  obtained  as  small  as  4  ounces. 

The  form  of  nozzle  devised  by  Politzer  is  a  slightly  curved  cone,  though 


EXAMINATIONS.  771 

each  bag  should  be  accompanied  by  a  short,  straight  tip  that  will  fit  in  the 
base  of  an  Eustachian  catheter.      It  is  exhibited  by  figure  1818. 


Figure  1819.    Nozzles  for  Politzer's  Bag. 

The  Nozzles,  outlined  in  figure  1819,  exhibit  the  three  forms  in  common 
use  for  ear  inflation.  Nozzle  "C"  is  a  slender  conical  tube  about  3  inches 
in  length,  slightly  curved.  Nozzle  "B"  is  an  oval  tube  about  i^  inches  in 
length,  the  tip  being  about  15  millimeters  wide  by  12  in  thickness.  Nozzle 
"A"  is  a  short  conical  tip  for  insertion  in  the  base  of  an  Eustachian  catheter. 

Manometers. 

These  consist  of  small  curved  tubes,  generally  in  "U"  form,  the  bow  or 
lower  portion  filled  with  mercury  or  other  fluid.  By  connecting  this  tube 
by  a  rubber  hose  with  a  close-fitting  ear-piece,  movements  of  the  tympanic 
membrane  may  be  determined.  They  are  employed  to  ascertain  the  mobil- 
ity of  the  membrane  by  inspection  during  inflation. 


Figure  1820.    Politzer's  Manometer. 

Politzer's  Manometer,  as  shown  in  figure  1820,  is  a  U-shaped  tube,  one 
arm  of  which,  near  its  center,  is  bent  at  an  angle  of  about  90°  and  secured 
in  a  soft  rubber  perforated  plug  of  a  size  that  will  fit  closely  in  the  external 
auditory  canal.  The  straight  arm  is  constructed  with  a  small  funnel-shaped 
opening,  by  means  of  which  liquid  may  be  dropped  or  poured  into  the  tube. 
By  closely  pressing  the  rubber  plug  into  the  external  canal  and  placing  one 
or  two  drops  of  red  ink  or  other  colored  fluid  in  the  tube,  the  movements  of 
the  membrane  during  inflation  will  be  indicated  by  the  rising  and  falling  of 
the  fluid  column 

Eustachian  Catheters. 

These  consist  of  slender  tubes  from  5  to  6  inches  in  length  and  provided 
with  a  beak-shaped  curve  at  the  distal  end  of  2  to  3  centimeters  in  extent, 
and  bent  at  an  angle  of  from  135°  (Barr)  to  145°  (Politzer).  They  are  em- 
ployed to  convey  fluids  to  the  Eustachian  tube  by  way  of  the  nasal  passages. 
They  are  usually  constructed  with  a  fixed  ring  or  projection  on  one  side  of 
the  proximal  end,  that  the  operator  may  know  the  direction  of  the  curve  of 
the  catheter  while  in  situ.  As  a  rule,  the  ring  is  placed  on  the  side  toward 
which  the  instrument  is  curved.  The  proximal  end  should  be  provided  with 
a  funnel-shaped  opening,  not  only  to  afford  a  firmer  and  better  grip,  but  to 
receive  a  conical  tip  by  means  of  which  a  Politzer  bag  or  other  inflating 
apparatus  may  be  connected.  They  are  manufactured  from  metal  and  hard 
rubber.  It  is  claimed  by  Politzer  that  the  latter,  when  correctly  and  care- 
fully made,  offer  superior  advantages.  His  claims  in  substance  are  the  fol- 
lowing: 

First,  that  while  this  material  possesses  sufficient  firmness  for  introduc- 
tion (because  forced  passages  are  never  attempted),  and  is  strong  enough  to 


772 


AURAL   SURGERY. 


enable  the  surgeon  to  feel  his  way  up  to  the  tube  opening,  it  is  still  elastic 
enough  to  conform  to  any  curves  ordinarily  encountered  in  the  nasal  pas- 
sages. Second,  the  ease  with  which  the  curve  can  be  altered  by  immersing 
the  tip  in  hot  water  for  a  few  seconds,  changing  the  shape  as  desired  while 
still  soft,  and  holding  in  position  until  cool.  Third,  that  they  do  not  re- 
quire warming,  as  is  the  case  with  metal  instruments,  and  that  they  are  not 
injured  by  contact  with  fluids. 

Metal  catheters  are  objectionable  to  many  operators  on  account  of  their 
rigidity  and  because  to  prevent  a  sense  of  chilliness,  they  must  be  warmed  be- 
fore introduction. 

On  the  other  hand,  most  American  authorities  recommend  those  made 
from  metal,  the  pattern  of  Blake  being  generally  preferred.  The  principal 
claim  is  that  greater  caliber  in  proportion  to  the  external  diameter  can  be 
•  secured  with  silver,  because  firm  walls  can  be  made  from  thinner  material, 
and  that  elasticity  is  unnecessary.  It  would  seem  that  more  depends  on 
fineness  and  correct  construction  than  material.  It  must  be  admitted  that 
nearly  all  of  the  hard  rubber  Eustachian  catheters  in  the  American  mar- 
kets are  of  cheap  German  construction  and  wholly  unfit  for  use. 

When  carefully  constructed,  they  are  slightly  bulbous  at  the  tip,  and  oval 
in  form,  the  long  diameter  being  at  a  right  angle  with  the  curvature  of  the 
catheter.  Remedies  in  small  quantities  may  be  injected  through  these  cathe- 
ters into  the  middle  ear.  Four  sizes  are  usually  found  necessary,  i%,  2^, 
3  and  3^  millimeters  in  external  diameter,  respectively. 


Figure  1821.    Plain  Eustachian  Catheter. 

The  Plain  Eustachian  Catheter,  which  maybe  seen  in  figure  1821,  is  the 
ordinary  form  above  described.  They  may  be  obtained  in  hard  rubber, 
brass,  nickel-plated  and  silver. 


Figure  1822.    Seiss'  Eustachian  Catheter  Syringe. 

Seiss'  Eustachian  Catheter  Syringe,  as  defined  in  figure  1822,  is  of  silver, 
closed  at  its  Eustachian  end,  the  sides  of  the  beak  or  curved  portion  having 
numerous  small  perforations.  By  means  of  a  slip  joint  it  may  be  attached 
to  a  syringe  of  about  2 -drachm  capacity.  The  latter  consists  of  a  hard  rub- 
ber barrel  with  metal  mountings,  the  plunger  rod  terminating  at  its  proxi- 
mal end  in  a  thumb-ring,  while  two  projecting  lateral  arms  furnish  counter- 
pressure  for  the  fingers.  Its  inventor  claims  that  with  it  the  Eustachian 
canal  may  be  thoroughly  cleansed  and  medicated  without  danger  of  injecting 
any  of  the  fluid  into  the  middle  ear. 

Catheter  Clamps. 

Catheter  clamps  are  occasionally  required  for  holding  a  Eustachian  cathe- 
ter in  place  in  cases  where  the  application  of  vapors  for  a  considerable  time 
is  advised. 

Pomeroy's-Kramer's  Eustachian  Catheter  Holder,  as  shown  in  figure  1823, 
consists  of  a  headband  similar  in  form  to  those  employed  for  holding 


EXAMINATIONS. 


773 


reflectors.  Like  the  latter,  it  is  provided  with  a  metallic  plate  to  which  is 
attached  a  small  post  provided  with  a  perpendicular  opening  and  set-screw. 
A  bifurcated  clamp,  the  opening  and  closing  of  which  is  controlled  by  a 
screw,  terminates  in  a  slender  rod  that  passes  through  the  opening  previously 


Figure  1823.     Pomeroy's-Kramer's  Eustachian 
Catheter  Holder. 


Figure  1824.    Wire  Catheter  Holder. 


referred  to.  By  means  of  a  set  screw  the  clamp  may  be  raised  or  lowered,  as 
desired,  while  a  Eustachian  catheter  may  be  firmly  held  in  situ  by  clasping 
it  between  the  jaws  of  the  holder. 

The  Wire  Catheter  Holder,  exhibited  in  figure  1824,  consists  of  two 
crossing  self-closing  fenestrated  blades,  the  whole  formed  from  a  single 
piece  of  steel  wire  much  after  the  pattern  of  the  plain-eye  speculum.  This 
instrument  may  be  used  for  holding  a  catheter  by  permitting  the  instrument 
to  clamp  the  septum  and  attaching  the  catheter  to  it  by  a  cord. 

Tympanic  Catheters. 

These  are  occasionally  required  for  injections  through  the  external 
auditory  canal  in  cases  of  perforation.  They  consist  of  a  slender  tube, 
either  of  metal  sharply  curved  or  of  elastic  material  made  soft  and  flexible. 


TRUAy-GREFKE 


Figure  1825.    Weber's-Liel's  Tympanic  Catheter. 

Weber 's-Liel's  Tympanic  Catheter,  as  depicted  in  figure  1825,  is  an  elastic 
woven  tube  about  i^  millimeters  in  diameter  and  17  centimeters  in  length, 
funnel  shaped  at  its  base,  covered  with  varnish  the  same  as  an  ordinary 
catheter,  and  the  whole  made  soft  and  pliable.  It  is  valuable  for  removing 
exudations  from  the  cavum  tympani  by  suction  as  well  as  for  injecting 
medicaments. 

Diagnostic  Tubes. 

Diagnostic  or  auscultation  tubes,  known  also  as  otophones,  are  soft  rubber 
tubes  employed  to  connect  the  external  auditory  canals  of  the  patient  and 
surgeon,  as  an  aid  in  diagnosing  certain  conditions  that  are  made  manifest 
by  sound  conveyed  to  the  ear  of  the  latter. 

Toynbee's  Diagnostic  Tube,  which  is  shown  in  figure  1826,  is  a  soft  rub- 
ber tube  about  18  inches  in  length,  terminating  at  each  end  in  an  olive- 
shaped  ear-tip  of  a  size  and  shape  that  will  fit  firmly  into  the  external  open- 
ing. It  is  advisable  that  the  two  tips  be  of  different  colors,  as,  for  instance, 
white  and  black,  or  red  and  black,  that  the  surgeon  may  at  all  times  appro- 


774 


AURAL    SURGERY. 


priate  the  same  one  for  his  own  use.  Pynchon  employs  an  ear-tip  provided 
with  a  small  lateral  opening,  that  in  cases  of  tympanic  perforation,  a  current 
of  air  will  contact  the  ear  of  the  operator. 


Figure  1826.     Toynbee's  Diagnostic  Tube.  Figure  1827.     Politzer's  Acoumeter. 

Middle  Ear  Mirrors. 

Mirrors  for  use  in  the  middle  ear  consist  of  small  reflectors  employed  in 
cases  of  tympanic  perforation.  They  are  usually  made  from  polished  metal, 
for  when  of  this  material,  they  can  be  manufactured  smaller  and  much 
lighter  than  glass  mirrors. 


Figure  1828.    Bishop's  Middle  Ear  Mirror. 


Bishop's  Middle  Ear  Mirror,  sketched  in  figure  1828,  is  a  small  circular 
disc  of  thin  material  mounted  on  a  slender  yet  flexible  wire  handle  that  is 
capable  of  being  bent  to  any  angle  desired.  It  may  be  procured  in  two 
sizes,  4  and  6  millimeters  in  diameter,  respectively. 


Figure  1829.    Blake's  Middle  Ear  Mirror. 


Blake's  Middle  Ear  Mirror,  as  may  be  seen  by  consulting  figure  1829, 
is  a  small  metallic  mirror  attached  to  a  slender  shaft  which  has  a  suitable 
handle  and  is  provided  with  mechanism  by  means  of  which  the  mirror  may 
be  rotated  in  any  desired  direction.  A  small  cam  attached  to  one  side  of 
the  rotating  mirror  shaft  is  attached  by  a  slender  bar  to  a  thumb-piece  actu- 
ating in  a  slot  provided  in  the  handle.  Two  mirrors,  one  6,  the  other  4  mil- 
limeters in  diameter,  form  a  set. 


EXAMINATIONS.  775 

Acoumeter. 

The  acoumeter  is  a  small  instrument  for  producing  uniform  soundwaves 
and  is  employed  for  the  accurate  determination  of  hearing  acuity.  It  is 
used  in  place  of  a  watch  in  tests  for  hearing,  because,  if  properly  constructed, 
it  produces  a  uniform  pitch  and  intensity.  It  may  be  iised  both  for  simple 
air  and  for  bone  conduction. 

Politzer's  Acoumeter,  the  shape  of  which  is  made  clear  in  figure  1827,  is 
a  horizontal  steel  cylinder  mortised  and  fitting  firmly  into  an  upright  hard 
rubber  column.  The  upright  column  terminates  at  each  end  in  T-shaped 
bars,  each  presenting  a  concave  outer  surface  by  means  of  which  a  firm  grasp 
on  the  instrument  between  the  thumb  and  forefinger  may  be  obtained. 
Parallel  to  and  hinged  directly  above  the  cylinder,  a  percussion  hammer  is 
fastened  in  an  oval  opening  in  such  a  manner  that  it  may  be  raised  and 
allowed  to  drop  by  force  of  gravity.  A  check  prevents  its  being  raised  be- 
yond a  given  height. 

The  steel  cylinder  is  bored  hollow  and  tuned  to  "C.  "  They  may  at  all 
times  be  tested  by  the  whistle,  caused  by  blowing  forcibly  into  the  opening. 
To  be  of  service,  all  the  instruments  must  be  alike,  with  all  parts  uniform, 
and  the  cylinders  must  be  correctly  tuned. 

For  bone  conduction,  connection  with  the  cranium  is  made  by  a  metallic 
disc  attached  to  a  shaft  projecting  from  one  side  of  the  instrument.  Patients 
not  able  to  hear  this  instrument,  may  be  tested  with  a  metronome.  A 
number  of  instruments  have  been  constructed  on  this  principle  to  move 
with  clock-work,  but  they  have  not  been  adopted  for  general  use. 

Tuning  Forks. 

For  diagnosing  diseased  conditions  of  the  ear,  ordinary  and  special  tun- 
ing forks  are  necessary.  They  are  useful  for  locating  diseased  condi- 
tions with  a  reasonable  degree  of  certainty. 

Usually,  they  are  of  the  ordinary  forked  pattern,  those  of  high  pitch 
being  short  and  heavy,  while  the  lower  numbers  are  more  slender  or  pro- 
vided with  large  discs  to  ensure  slow  vibrations.  Some  patterns  are  pro- 
vided with  spring  hammers  with  a  view  of  obtaining  a  uniform  blow  on  the 
instrument. 

Over-tones  are  in  many  instances  prevented  by  the  use  of  sliding  clamps. 
These  can  be  moved  as  desired  and  secured  by  set  screws. 

Tuning  forks  are  suitable  for  both  air  and  bone  conduction  and  may  be 
procured  singly  or  in  sets  varying  from  20  to  16,384  vibrations  per  second. 
Different  authorities  recommend  sets  containing  from  three  to  nine  instru- 
ments in  each.  Ordinarily,  three  should  be  employed:  C=i28;  C2=5i2 
and  C4=2,o48.  If  the  operator  is  confined  to  a  single  instrument,  C2=5i2 
is  recommended. 

For  low  tones  C=i28  will  answer  in  most  cases,  but  in  some  ^=64  or 
02—32  are  necessary.  An  instrument  as  low  as  20  has  been  devised  by 
Politzer.  For  the  higher  tones  C4=2,o48  and  C5=4,o96  are  frequently 
employed. 


Figure  1830.     Plain  Tuning  Fork. 

The  Plain  Tuning  Fork,  delineated  in  figure  1830,  represents  the  ordi- 
nary tuning  fork  employed  for  musical  use.  They  may  be  obtained  in  both 
"C"  and  "A."  They  are  usually  C2=si2, 


776 


AURAL    SURGERY. 


Hartmann's  Tuning  Forks,  as  shown  in  figure  1831,  comprise  a  series  of 
five  instruments  tuned  to  128,  256,  512,  1,024  and  2,048  vibrations  per  second, 
respectively.  They  represent  the  "C's"  of  the  four  higher  octaves,  begin- 


Figure  1831.    Hartmann's  Tuning  Forks. 


ning  at  the  "C"  below  middle  "C"  of  the  piano  scale.  The  two  lower  ones 
are  constructed  with  sliding  weights,  to  prevent  over- tones  and  to  raise  and 
lower  the  pitch. 


Figure  1832.    Bishop's  Tuning  Fork. 

Bishop's  Tuning  Fork,  as  illustrated  in  figure  1832,  is  one  of  512  vibra- 
tions per  second,  the  universal  standard  of  pitch.  It  is  C2,  or  one  octave 
above  middle  "C"  of  the  piano.  It  differs  from  the  patterns  previously  de- 
scribed in  that  it  is  provided  with  an  automatic  hammer  attachment,  by 
which  a  moderate  blow  of  unvarying  force  may  be  given.  The  hammer  is 
poised  with  the  head  removed  a  short  distance  from  one  of  the  forks  of  the 
instrument.  It  is  attached  to  the  handle  by  means  of  a  post  and  provided 
with  plain  steel  springs,  one  upon  either  side  of  the  post,  by  which  the 
hammer  shaft  is  held  in  place  when  in  a  state  of  rest. 


EXAMINATIONS.  777 

Galton's  "Whistle. 

Gallon's  Whistle,  as  illustrated  by  figure  1833,  consists  of  a  shrill  whistle 
operated  by  compressing  a  rubber  bulb.  It  is  often  employed  instead  of 
the  tuning  fork  in  testing  for  the  higher  notes.  The  length  of  the 


Figure  1833.    Galton's  Whistle. 


cylindrical  sound  chamber  may  be  regulated  by  a  micrometer  screw  care- 
fully graduated  by  an  accurate  scale.  It  is  so  constructed  that  a  hollow 
cylinder  extends  over  and  around  the  inner  or  sound-creating  cylinder.  On 
one  side  is  a  scale  showing  the  tens,  and  around  it  another  showing  the 
single  numbers.  The  whistle  has  a  compass  of  three  octaves  with  6,841  to 
84,000  vibrations  per  second.  For  still  higher  tones  Koenig's  cylinders  are 
recommended.  They  vary  from  20,000  to  100,000  vibrations  to  the  second. 

Probes. 

Probes  for  use  in  the  ear  are  usually  constructed  from  soft  pure  silver. 
They  are  convenient,  not  only  for  the  examination  of  growths,  sinuses, 
etc. ,  but  for  removing  foreign  bodies,  making  applications,  etc. 

TBUAX  CPLENE    -  CQ. 

Figure  1834.     Buck's  Ear  Probe. 

Buck's  Ear  Probe,  as  drawn  in  figure  1834,  is  of  pure  silver,  slender  in 
construction  and  has  a  slight  bulbous  tip. 

OPERATIONS  ON  THE  MASTOID. 

Operations  on  the  mastoid  process  will  require  the  following  instru- 
ments : 

Minor  operating  list  on  pages  270  to  275. 

Periosteal  elevator  for  loosening  and  turning  back  periosteum,  figures 
844  to  849. 

Retractors  for  separating  lips  of  wounds. 

Guide  for  directing  instruments  or  locating  parts. 

Chisels  for  primary  bone  incision. 

Gouges  for  enlarging  bone  opening. 

Mallet  for  driving  gouges  and  chisels,  figures  827  to  829. 

Bone  scoops  for  cleaning  out  granulations,  necrosed  tissues,  etc.,  fig- 
ures 804  to  809. 

Small  sequestrum  forceps  for  removing  bone  fragments. 

Trephine,  in  cases  of   brain  abscess,  figures  882  to  889. 

Ear  mirror  for  inspecting  the  deeper  portions  of  the  wound,  figures 
1460  to  1466. 

Dental  engine,  with  burr-shaped  drills,  figures  874  to  880. 


778 


AURAL    SURGERY. 

Mastoid  Retractors. 


Retractors  are  necessary  to  prevent  the  soft  tissues  from  closing  the 
wound  opening.  While  the  ordinary  patterns,  particularly  those  of  small 
size  and  with  short  blades  or  teeth,  will  answer  the  purpose,  special  instru- 
ments are  employed  by  many  operators.  If  a  mastoid  retractor  is  not  avail- 
able, the  sharp-toothed  retractors  of  Volkmann,  shown  by  figure  618,  may  be 
used.  The  special  forms  are  usually  of  the  self-retaining  pattern  and  de- 
signed with  a  view  of  presenting  mechanism  by  which  the  blades  may  be 
spread  nearly,  if  not  quite,  parallel  to  each  other. 


Figure  1835.    Bishop's  Mastoid  Retractor. 


Figure  1836.     Andrews'  Mastoid  Retractor. 


Bishop's  Retractor,  as  delineated  in  figure  1835,  possesses  the  advantage 
that  the  blades  may  be  extended  either  parallel  or  at  an  angle  with  each 
other.  This  latter  feature  enables  the  operator  to  conform  the  instrument 
to  any  inequalities  of  wound  incision  or  tissue  tension.  Any  width  may  be 
obtained,  up  to  2  inches.  The  hooks  are  sharp,  ten  on  each  blade,  while  the 
space  occupied  by  the  hooks  upon  each  blade  is  about  2  inches.  This  space 
may  be  reduced  in  one  or  both  blades  to  i  inch  by  removing  a  telescoping 
section  upon  which  five  of  the  hooks  are  placed.  In  such  cases  the  opening 
in  the  end  of  the  shaft  caused  by  the  removal  of  the  telescoping  part  referred 
to  should  be  closed  with  gauze,  wax  or  absorbent  cotton.  After  being  used, 
this  opening  should  be  carefully  dried  and  filled  with  oil,  that  no  rusting 
may  occur.  The  screw  device,  by  which  the  instrument  may  be  maintained 
at  any  desired  width  or  angle,  is  shown  in  the  illustration. 

Andrews'  Mastoid  Retractor,  as  shown  in  figure  1836,  has  two  parallel 
arms,  each  supplied  with  a  row  of  hooked  teeth  and  united  by  a  cross-bar  by 
means  of  which  any  desired  amount  of  separation  may  be  maintained.  The 
cross-bar  is  permanently  attached  to  one  arm  and  slides  through  two  slots 
in  the  other,  so  adjusted  that  when  pressure  is  made  upon  the  teeth,  the 
arm  becomes  firmly  locked  to  the  bar.  The  lock  is  released  by  pressure 
upon  the  handles  at  the  proximal  ends  of  the  blades.  Each  arm  has  five 
teeth  and  is  provided  with  an  extension  bar  carrying  four  additional  teeth, 
as  shown  in  the  figure.  The  extension  bar  may  be  so  applied  as  to  increase 
its  length  by  one,  two,  three  or  four  teeth,  thus  furnishing  an  instrument 
suited  to  the  needs  of  almost  anv  case. 


Figure  1837.     Allport's  Improved  Retractor. 

Allport's  Retractor  consists  of  two  parallel  arms  attached  by  hinges  to  a 
base  and  caused  to  diverge  by  means  of  a  toggle  joint  controlled  by  a  screw 


MASTOID    OPERATIONS. 


779 


device.  As  the  width  of  the  base  is  about  the  same  as  that  of  the  average 
wound  in  mastoid  operations,  the  blades  when  in  use  are  nearly,  if  not 
quite,  parallel.  The  hooks  are  curved,  blunt-pointed  and  eighteen  in  num- 
ber, nine  upon  either  side,  occupying  a  space  of  about  2  inches  in  extent. 
Any  amount  of  dilatation  desired  may  be  secured. 

Mastoid  Guide. 


Figure  1838.    Bishop's  Mastoid  Guide. 

Bishop's  Mastoid  Guide,  as  depicted  in  figure  1838,  according  to  its  in- 
ventor, serves  not  only  as  a  guide  in  mastoid  operations  but  as  a  periosteal  ele- 
vator for  the  canal,  and  to  protect  the  facial  nerve  and  other  adjacent  struct- 
ures from  injury.  It  is  used  by  inserting  the  foot  plate  in  the  auditory 
canal,  while  chiseling  along  the  posterior  wall  of  the  bony  meatus,  that^the 
surgical  relations  of  the  parts  may  be  kept  in  view.  It  is  also  employed  to 
advantage  in  separating  the  periosteum  and  integument  from  the  osseous 
canal,  and  in  some  operations  it  is  inserted  into  the  attic,  the  narrow  toe  of 
the  foot  plate  being  passed  through  the  aditus  ad  antrum,  so  as  to  lie  over 
and  protect  the  facial  nerve. 

Gouges. 

These  differ  from  the  pattern  shown  by  figure  812,  in  being  smaller 
and  of  more  delicate  construction.  They  are  used  by  most  operators  for 
making  the  first  incision  through  the  cranial  cortex.  Politzer  recommends 
a  set  of  four,  3^,  5,  6  and  8  millimeters  in  width,  respectively. 

fllllllllllllllllilillllliiM 

Figure  1839.     Schwartz's  Gouge. 

Schwartz's  Gouge,  as  drawn  in  figure  1839,  is  made  from  solid  steel,  is 
about  4  inches  in  length  and  may  be  obtained  in  the  sizes  advised  by  Polit- 
zer. A  similar  pattern,  however,  may  be  procured  from  most  dealers  2^ 
millimeters  in  breadth. 


THUHX    CREENiaCO 


Figure  1840.     Bishop's  Gouge. 


Bishop's  Gouge,  as  delineated  in  figure  1840,  is  of  slender  construc- 
tion, usually  about  6^  inches  in  length.  They  are  manufactured  in  the  sizes 
advised  by  Politzer,  and  are  constructed  with  well-rounded  cutting  blades, 
ground  thin  for  easy  penetration. 

Chisels. 

Chisels,  lighter  and  smaller  than  those  described  by  figure  810,  are  also 
required.  By  some  operators  they  are  used  for  the  first  bone  incision,  al- 
though they  are  usually  employed  for  enlarging  the  opening,  for  trimming 
irregularities  and  cutting  away  projecting  speculae.  Unlike  those  used  in 
general  surgery,  they  should  be  constructed  with  center  edges. 


Figure  1841.    Bishop's  Chisel. 

Bishop's  Chisel,  as  described  by  figure   1841,  is  manufactured  in  three 
widths,  each  3^,5  and  6  millimeters. 


780 


AURAL    SURGERY. 


Buck's  Chisels,  as  illustrated  in  figure  1842,  differ  from  the  pattern  of 
Schwartz,  in  being  shorter  and  heavier.  They  are  usually  about  3  inches 
in  length  and  of  two  sizes,  3^  and  5  millimeters  in  width. 


Figure  1842.     Buck's  Chisels. 

Scoops. 

Small  and  delicate  scoops  for  removing  cheesy  material,  necrosed  bone 
and  fungoid  growths,  are  often  required  in  an  operation.  Ordinarily,  they 
are  employed  to  scrape  out  a  cavity  before  disinfection.  Like  chisels  and 
gouges,  they  differ  from  those  employed  in  general  bone  surgery  principally 
in  being  smaller  Valuable  patterns  can  be  selected  from  those  shown  by 
figures  804  to  808.  A  special  set  devised  for  this  class  of  work  is,  however, 
here  exhibited. 


Figure  1843.    Bishop's  Bone  Scoops 


Bishop's  Bone  Scoops,  as  shown  by  figure  1843,  form  a  set  composed  of 
one  spoon,  two  scoops  and  three  curettes ;  the  set  of  six  comprising  three  in- 
struments, each  being  double.  The  spoon  has  dull  margins,  about  7  mil- 
limeters in  diameter.  The  scoops  are  circular  in  form,  with  sharp  cutting 
edges,  5  and  6  millimeters  in  diameter,  respectively.  The  two  larger 
curettes  are  oval,  with  sharp-cutting  edges,  one  6,  the  other  5  milli- 
meters, in  its  short  diameter.  The  small  curette  for  scraping  out  minute 
cavities  in  the  middle  ear  is  constructed  on  a  slender  shank,  and  is  cir- 
cular in  form,  with  an  external  diameter  from  3  to  3^  millimeters. 


REMOVAL  OF  POLYPI. 

Polypi  may  be  removed  by  avulsion,  ligation,  ecrasement,  excision, 
crushing,  galvano-cautery  and  caustics,  all  of  which  methods  should  be  pre- 
ceded by  the  free  use  of  the  syringe  or  douche,  that  the  meatus  may,  as  far 
as  possible,  be  rendered  sterile.  This  may  be  followed  by  cocainizing 
with  a  10  per  cent,  solution. 

Avulsion. 

This  may  be  secured  by  polypus  forceps,  snares  and  hooks 

Polypus  Forceps. 

Small  polypi,  particularly  those  with  well-defined  pedicles,  may  some- 
times be  removed  by  polypus  forceps.  Such  instruments,  owing  to  the  lim- 
ited space  in  which  they  must  open,  with  width  sufficient  to  grasp  the  poly- 
pus, must  be  of  slender  and  delicate  construction.  Care  must  be  taken, 


REMOVAL    OF    POLYPI. 


781 


however,  in  selecting  an  instrument  to  secure  one  that  will  extract  the 
growth  complete,  without  incurring  the  danger  of  tearing  away  only  a 
piece  of  it. 


Figure  1844.    Politzer's  Polypus  Forceps. 

Politzer's  Polypus  Forceps,  as  detailed  in  figure  1844,  have  straight  han- 
dles, are  about  5^  inches  in  length  and  curved  on  the  edge.  The  jaws 
in  their  long  diameter  are  hollow  and  concave,  closing  firmly  together 
at  their  extreme  tips.  Spoon-shaped  depressions  are  formed  in  the  inner 
side  of  each  jaw,  the  borders  being  finely  serrated.  The  extreme  width 
should  not  exceed  4  millimeters. 


Figure  1845.     Pond's  Polypus  Forceps. 


Pond's  Polypus  Forceps,  as  shown  in  figure  1845,  differ  from  the  pattern 
of  Politzer,  in  being  a  trifle  longer,  with  stronger  blades  and  longer  and 
heavier  jaws.  The  width  of  the  latter  is  about  3^  millimeters. 


Figure  1846.    Noyes'  Polypus  Forceps. 


Noyes'  Polypus  Forceps,  as  exhibited  in  figure  1846,  are  of  the  double- 
lever  type,  of  slender  construction,  with  alligator-shaped  jaws.  As  the  body 
of  the  instrument  is  slender,  it  is  well  adapted  for  operating  through  a 


Figure  1847.    Troeltsch's  Polypus  Forceps. 

speculum.     Without  expanding  the  main  portion  of  the  instrument,  the 
operator  may  secure  a  considerable  space  between  the  tips  of  the  jaws. 


782 


AURAL    SURGERY. 


The  latter  are  grooved  along"  their  inner  faces,  the  margins  being  trans- 
versely serrated  As  the  instrument  is  bent  downward  on  the  edge,  the 
view  of  the  operating  field  is  not  obstructed  by  the  hand. 

Troeltsch's  Polypus  Forceps,  as  may  be  seen  by  referring  to  figure 
1847,  differ  from  the  patterns  last  described,  in  that  they  are  constructed 
in  a  bayonet  form,  the  shanks  and  jaws  being  straight.  The  width  of  the 
latter  are  usually  about  4  millimeters. 


Figure  1848.     Lange's  Ear  Forceps. 


Lange's  Forceps,  as  indicated  in  figure  1848,  are  not  only  in  bayonet 
form  but  the  handles  are  angular  bent  downward,  thus  affording  a  conven- 
ient and  handy  grasp.  While  the  shanks  of  this  instrument  are  firm  and 
heavy  a  delicate  taper  is  secured  near  the  tips,  the  latter  terminating  in 
small  minute  concave  scoops  about  2  millimeters  in  diameter.  For  operating 
through  a  speculum  where  economy  of  space  is  important,  this  instrument 
possesses  many  advantages.  With  it  small  particles  may  be  easily  grasped 
and  extracted.  In  order  to  obtain  the  greatest  amount  of  power,  the 
handles  are  somewhat  widely  spread  that  the  full  spring  of  the  blades  may 
be  secured.  The  length  of  the  instrument  is  about  7  inches. 

Tumors  of  the  ear  may  oftentimes  be  removed  by  avulsion  with  a  snare 
either  of  the  Wilde  pattern  or  some  modification  thereof.  In  operating, 
the  wire  loop  is  passed  over  the  growth,  tightened  sufficiently  to  obtain  a 
firm  grasp,  after  which  the  polypus  is  removed  by  traction.  Steel,  soft 
annealed  iron  and  brass  wire  are  recommended  for  this  purpose.  All  may 
be  procured  in  spools  containing  about  five  yards  or  in  coils  of  %  Ib.  each, 
the  latter  being  the  more  economical.  Snares  for  linear  excision  will  be 
found  described  by  figures  1704  to  1710. 


Figure  1849.    Wilde's  Snare. 


Wilde's  Snare,  as  set  forth  in  figure  1849,  consists  of  a  shaft  bent  near  its 
center  at  an  angle  of  about  135°.  The  proximal  half  is  a  plain  square  shaft 
upon  which  a  loosely  fitted  sliding  bar  may  be  moved  back  and  forth.  This 
bar  terminates  upon  either  side  in  pin-like  projections,  which  serve  as  finger 
holds  by  means  of  which  traction  is  produced.  The  distal  half  of  the  shaft 
is  slender  and  provided  with  wing-like  projections,  both  at  its  tip  and  at  a 
point  just  back  of  the  bend.  These  wings  are  perforated  by  openings 
parallel  with  the  shaft,  a  third  set  of  openings  being  provided  in  the  sliding 
bar  previously  referred  to. 


REMOVAL    OF    POLYPI.  783 

These  perforations  are  so  adjusted  that  the  two  ends  of  the  wire  loop 
may  be  passed  backward  through  the  openings  at  the  tip,  then  through 
those  near  the  center  of  the  shaft  and  finally  through  those  provided  in  the 
moving  cross-bar,  to  which  after  the  substance  to  be  severed  has  been  encir- 
cled and  the  wires  drawn  tight,  they  may  be  fastened.  The  extreme  width 
of  the  distal  end  should  not  exceed  3  millimeters,  and  the  tip  should  present 
a  smooth  and  well-rounded  surface.  This  pattern,  once  quite  popular, 
now  commands  only  a  limited  sale,  as  it  is  not  suitable  for  general  purposes 
as  are  the  later  improved  patterns  of  Blake,  Burnett  and  others,  as  de- 
scribed by  figure  1850. 


Figure  1850.     Blake's  Snare. 

Blake's  Snare,  as  shown  by  figure  1850,  is  somewhat  lighter  than,  and  is 
generally  considered  an  improvement  on  the  pattern  of  Wilde.  The  thumb 
ring  is  so  attached  that  it  may  be  rotated  to  the  right  or  left,  as  may  be 
most  convenient.  The  sliding  bar  is  replaced  with  a  square  collar,  upon 
the  upper  side  of  which  a  post  is  firmly  riveted  and  to  which  the  wires  may 
be  secured.  A  strong  finger  ring  is  attached  to  the  under  surface  by  means 
of  which  the  snare  is  manipulated.  The  proximal  portion  of  the  shaft  is  in 
canula  form,  the  tip  somewhat  flattened,  and  the  central  part  of  the  open- 
ing filled  with  a  square  shouldered  division  post,  upon  each  side  of  which 
the  wire  is  caused  to  actuate.  As  the  instrument  is  separable,  minute  can- 
ulas  for  removing  intra-tympanic  growths  may  be  provided  and  employed 
with  the  same  handle. 

Ligation. 

This  necessitates  the  use  of  a  loop  of  wire  or  other  ligature  and  means 
for  twisting  the  same  around,  the  base  of  a  growth  so  as  to  arrest  circulation, 
thus  causing  strangulation  and  necrosis.  The  ligature  would  better  be  of 
soft  wire,  either  annealed  iron  or  silver,  the  former  being  usiially  preferred. 
The  loop  may  be  adjusted  and  twisted  by  means  of  several  instruments, 
among  which  are  avulsion  snares,  see  figures  1849  and  1850;  snare  forceps 
and  Gooche's  canula. 

Snare  Forceps,  as  set  forth  in  figure  1852,  are  forceps-like  instruments, 
the  blades  of  which  consist  of  straight  slender  canulas,  through  each  of 
which  the  ends  of  a  wire  loop  may  be  passed.  Upon  one  blade  a  sliding 
ring  is  provided  to  which  the  ends  of  the  wires  may  be  attached  by  a  suitable 
post.  By  opening  and  closing  the  blades  of  the  instrument,  an  easy  means 
is  furnished  for  the  proper  placing  of  the  wire  loop.  After  the  loop  is  in 


784  AURAL    SURGERY. 

place,  the  instrument  may  be  rotated  and  the  loop  twisted  until  the  proper 
amount  of  constriction  is  secured.  The  wires  may  then  be  cut  near  the 
points  and  the  forceps  withdrawn,  leaving  the  loop  in  situ. 


Figure  1853.    Snare  Forceps. 


Gooche's  Canula,  as  will  be  seen  by  figure  1853,  consists  of  two  slender 
tubes,  united  by  being  soldered  together,  thus  forming  a  double-channel 
canula.  In  order  to  avoid  injuring  tne  soft  tissues,  the  ends  are  guarded 
with  rings  and  carefully  smoothed  and  rounded.  The  entire  width  of  the 
two  canulas  should  not  exceed  5  or  6  millimeters.  Both  ends  of  the  wire 


Figure  1853.    Gooche's  Canula. 

loop  may  be  passed  through  the  canula,  the  wire  adjusted,  drawn  tight, 
twisted  together  at  the  proximal  end  of  the  canula,  when,  by  rotating  the 
latter,  the  wires  may  be  twisted  at  the  distal  end,  thus  tightly  encircling  the 
enclosed  mass.  If  desired,  the  wires  may  afterward  be  cut  and  the  canula 
removed,  as  described  in  the  last  mentioned  instrument. 

r 

Ecrasement. 

This  may  be  secured  by  means  of  snares.  Several  patterns  are  in  use, 
nearly  all  of  which  are  described  in  a  chapter  devoted  to  nasal  instruments. 

Ecrasement  Snares. 

Snares  for  ecrasement  differ  from  those  of  the  Wilde  pattern  in  the  em- 
ployment of  a  single  canula  or  its  equivalent,  through  which  both  ends  of 
the  wire  loop  are  drawn.  As  the  loop  may  be  drawn  completely  within 
the  canula,  any  soft  substance  encircled  by  it  may  be  severed  and  complete 
division  thus  secured. 

Catgut  and  silkworm  gut  are  not  often  employed  for  this  purpose,  be- 
cause neither  material  possesses  sufficient  stiffness  to  admit  of  its  being 
readily  passed  over  or  around  the  growth  to  be  removed. 

Excision. 

The  most  available  instrument  with  which  to  remove  a  tumor  from  the 
ear  by  excision  is  a  circular  knife. 

Ring  Knives. 

These  resemble  a  sharp  curette.  They  are  adapted  for  removing  soft 
sessile  polypi  by  morcellement.  They  are  applicable  in  cases  where  it  is 
found  impossible  to  enclose  the  mass  with  a  wire  loop. 


REMOVAL   OF    POLYPI.  785 

Politzer's  Curettes,  as  set  forth  in  figure  1855,  consist  of  circular  curettes 
provided  with  a  cutting  edge  in  the  form  of  a  ring  having  a  sharp  inner 
margin.  For  growths  in  the  lower  and  posterior  meatus  wall,  special  knives 
with  rings  at  an  angle  with  the  shaft  should  be  provided.  They  are  usually 
in  four  sizes,  the  external  diameters  of  the  rings  being  i^,  2,  3  and  $% 


Figure  1855.    Politzer's  Curettes  or  Ring  Knives. 

millimeters,  respectively.  The  rings  and  shafts  should  all  fit  a  single 
handle  and  be  held  in  place  by  a  suitable  set- screw.  The  handle  should 
be  angular  bent,  so  that  the  operator's  hand  will  not  encroach  on  the  field 
of  vision. 

Crushing. 

This  is  adapted  to  growths  on  the  inner  section  of  the  anterior  inferior 
wall  of  the  meatus.  It  is  secured  by  a  special  forceps  of  good  size,  with 
strong  blades  and  jaws. 


Figure  1856.     Politzer's  Polypus  Forceps. 


Politzer's  Polypus  Crushing  Forceps,  as  depicted  in  figure  1856,  are  knee- 
bent  and  provided  with  jaws  having  grooved  inner  surfaces.  Two  forms 
should  be  provided,  one  with  a  curved,  the  other  with  a  square,  terminal 
border.  The  width  of  the  jaws  should  not  exceed  5  millimeters. 

Galvano-Cautery. 

The  galvano-cautery  may  be  used  in  the  external  meatus  after  failure 
of  the  previously  mentioned  instruments.  Plain  round  points  are  best 
adapted  for  granulations  and  small  tumors,  and  flat  tips  with  round  ter- 
minal margins  for  the  larger  growths. 

Chemical  Caustics. 

Caustics,  whether  for  the  destruction  of  polypi  or  arrest  of  hemor- 
rhage, may  be  applied  by  applicators  or  probes. 

Bishop's  Caustic  Applicator,  as  sketched  in  figure  1857,  is  a  flexible, 
tapering  wire  rod  to  the  end  of  which  a  platinum  loop  is  secured.  This  is 
particularly  adapted  for  the  application  of  chromic  acid.  By  dipping  the 

Figure  1857.     Bishop's  Caustic  Applicator. 

end  of  the  loop  in  mucilage  and  bringing  it  into  contact  with  crystals  of 
chromic  acid,  the  latter  will  adhere  sufficiently  to  enable  the  operator  to 
fuse  them  in  the  heat  of  a  spirit  lamp,  where,  with  proper  care,  they  will 
form  a  bead  or  tear  that,  upon  cooling,  will  adhere  firmly  to  the  wire. 

50 


786  AURAL    SURGERY. 


REMOVAL  OF  EXOSTOSES. 

The  surgical  removal  of  exostoses  and  hyperostoses  will  require  a  part, 
if  not  all,  of  the  same  general  list,  as  printed  on  page  777,  recommended  for 
perforating  the  mastoid  process. 

REMOVAL    OF  FOREIGN  BODIES. 

Foreign  bodies  in  the  auditory  canal  are  frequently  the  source  of  much 
trouble  to  the  operator.  An  attempt  at  correction  is  sometimes  more  dan- 
gerous to  the  patient  than  the  presence  of  the  foreign  substance.  Instru- 
ments other  than  the  syringe  should  be  used  with  great  care,  and  the  latter 
is  usually  contraindicated  in  cases  of  tympanic  perforation.  The  selection 
of  a  method  must  depend  on  the  location,  nature,  shape,  size  and  condition 
of  the  surrounding  parts.  All  foreign  bodies  should  be  removed  by  means 
of  a  syringe  filled  with  warm  soapy  water  where  possible.  This  applies  to 
the  removal  of  inspissated  cerumen  as  well  as  of  other  substances. 

If  the  substance  be  a  vegetable  product  and  cannot  be  removed  by  a 
syringe,  it  should  be  subjected  to  a  small  stream  of  alcohol  that  it  may  not 
swell  by  the  absorption  of  water. 

The  use  of  ordinary  dressing  forceps  should  be  avoided,  for,  as  a  rule, 
they  only  serve  to  wedge  the  substance  more  firmly  and  to  force  it  farther 
into  the  canal. 

Living  insects  may  be  killed  by  filling  the  cavity  with  water  or  mineral 
oil,  and  allowing  it  to  remain  for  10  minutes,  after  which  it  may  be 
washed  out  with  a  syringe.  Tobacco  smoke  has  also  been  recommended 
for  this  purpose.  Larvae  may  be  killed  by  alcohol,  chloroform  vapor,  or 
oil.  Leeches,  if  they  escape  into  the  ear,  may  be  killed  with  normal  salt 
solution.  Small  objects  exerting  no  pressure  on  the  walls  may  usually  be 
removed  by  the  syringe.  As  the  canal  is  oval,  a  space  may  usually  be 
found  on  one  side  into  which  a  stream  of  water  can  be  injected.  Large 
objects  tightly  impacted  require  instrumental  interference.  Care  should 
be  exercised,  however,  not  to  force  the  object  farther  into  the  canal.  Occa- 
sionally substances  will  require  removal  by  piecemeal.  All  instruments 
employed  should  be  fine  and  delicate. 

Beads  have  been  removed  particularly  when  turned  with  an  opening  in 
line  with  the  external  meatus,  by  the  insertion  of  the  point  of  a  sponge 
tent,  the  latter  being  allowed  to  swell  by  the  application  of  water.  Wooden 
balls,  cherry  stones,  and  other  dry  substances  have  been  extracted  by 
dipping  a  camel's  hair  pencil  in  strong  glue,  placing  it  in  contact  with  the 
substance  to  be  removed,  holding  it  in  place  until  thoroughly  dry,  and  re- 
moving the  substance  by  traction. 

Among  the  instruments  employed  for  this  purpose,  a  portion  of  which 
will  be  required  in  certain  cases,  are  a  head-mirror,  speculum,  syringes, 
hooks,  spoons  and  forceps. 


Figure  1860.     Lister's  Ear  Hook. 

Lister's  Ear   Hook,   as  traced  in  figure  1860,  consists  of  a  handle  and 
slender  shank,  about  5  millimeters  of  the  point  being  laterally  bent  and 


REMOVAL    OF    FOREIGN    BODIES. 


787 


slightly  curved  on  the  flat.  This  instrument,  although  of  delicate  con- 
struction, is  not  liable  to  injure  the  meatus  walls.  Its  curve  should  fit 
closely  to  the  internal  opening  that  it  may  be  crowded  between  the  tissues 
and  the  foreign  substance. 

Spoons. 

These  are  delicate  instruments  with  spoon-shaped  bowls  applicable  in 
cases  where  substances  of  a  friable  nature  are  encountered,  or  where  there 
is  danger  of  tissue  injury  if  sharp  instruments  be  used. 


Figure  1861.    Ear  Spoon. 


The  Ear  Spoon,  delineated  in  figure  1861,  consists  of  a  double-end  instru- 
ment, one  end  3  and  the  other  5  millimeters  in  diameter.  They  usually  have 
doubly  curved  handles  and  are  made  from  hard  rubber.  By  immersion  in 
hot  water  the  tips  may  be  changed  in  form  to  meet  the  requirements  of 
special  cases. 


Figure  1862.     Gross'  Ear  Spoon  and  Hook. 

Gross'  Ear  Spoon  and  Hook,  as  drawn  in  figure  1862,  comprises  two  val- 
uable instruments  in  one.  As  originally  designed  by  its  inventor,  it  was  of 
delicate  construction,  with  a  fine  hook  and  a  small  thin-walled  spoon.  Un- 
fortunately, instrument  makers  have  constructed  this  instrument  to  sell  at  a 
low  price  and  have  placed  one  in  nearly  every  pocket  case  of  instruments. 
The  result  is  that,  as  a  rule,  they  are  so  coarse  and  clumsy  as  to  be  fit  only 
for  work  in  the  nose  where  delicacy  of  construction  is  not  so  essential. 

Foreign  Body  Forceps. 

These  are  usually  slender  blades  arranged  for  encircling,  or  sharp- 
pointed  blades  for  penetrating  foreign  substances.  As  they  are  ordinarily 
inserted  through  a  speculum,  they  must  be  of  delicate  construction,  with 
slender  tips,  designed  for  operating  in  a  small  space. 


Figure  1863.     Guye's  Foreign  Body  Forceps. 


Guye's  Foreign  Body  Forceps,  as  illustrated  in  figure  1863,  have  delicate 
straight  shanks,  each  jaw  fenestrated  similar  to  an  obstetrical  forceps. 
Like  the  latter  the  blades  may  be  easily  disjointed  and  introduced  sepa- 
rately. The  lateral  diameter  of  the  blade  does  not  exceed  5  millimeters, 
the  whole  length  of  the  forceps  being  about  5  inches. 

Politzer's  Foreign  Body  Forceps,  as  disclosed  in  figure  1864,  are  slender, 
knee-bent  with  fenestrated  blades,  having  serrated  margins.  The  instru- 
ment is  usually  about  5  inches  in  length. 


788  AURAL    SURGERY. 

Tenaculum  Foreign  Body  Forceps,   as  shown  in  figure  1865,  consist  of  a 
double  tenaculum,  slender  and  delicate  in  construction,  similar  in  design  to 


Figure  1864.     Politzer's  Foreign  Body  Forcep. 

the  well-known  American  bullet  forceps.     This  pattern  will  be  found  use- 
ful in  grasping  bodies  that  can  be  penetrated,  for  in  many  cases  a  firm  grasp 


Figure  1865.    Tenaculum  Ear  Forceps. 


may  be  obtained  upon  such   a  substance  which  otherwise  could  not  be 
grasped. 

CONSTRICTION  OF  THE  EUSTACHIAN   TUBE. 

Constriction  of  the  Eustachian  tube  requires  the  use  of  bougies.  These 
are  usually  introduced  through  a  Eustachian  catheter. 

Eustachian  Bougies. 

These  are  delicate  and  quite  pliable,  yet  offer  sufficient  resistance  to 
pass  through  many  constrictions.  They  may  be  of  elastic  silk  web,  silk- 
worm gut,  catgut  or  whalebone. 


TRUAX,  GREENE  &  Co 
Figure  1866.     Elastic  Eustachian  Bougies. 

Silk  Elastic  Eustachian  Bougies,  as  traced  in  figure  1866,  differ  from 
the  filiform  patterns  described  in  the  urethral  section  in  being  of  still  finer 
and  more  delicate  construction.  They  may  be  usually  obtained  in  three 
sizes. 

Silkworm  Gut  furnishes  a  fairly  good  substitute  for  elastic  silk  web. 
The  cut  ends  must  be  deprived  of  their  sharp  margins  before  use. 

Catgut  Bougies  are  seldom  employed  except  as  dilators.  For  this  pur- 
pose they  are  allowed  to  remain  in  position  until  they  swell  or  enlarge  by 
the  absorption  of  fluid.  When  desired,  they  may  be  previously  soaked  in  a 
proper  medicament  and  dried  before  introduction. 

Whalebone  Bougies  are  usually  preferred,  because  they  furnish  greater 
resistance  in  proportion  to  their  elasticity,  and  may  thus  be  more  readily 
passed  through  a  constriction.  They  may  be  conical,  olive-shaped  or 
.cylindrical.  They  should  be  well  polished  and  rounded,  presenting  a 


ARTIFICIAL     PERFORATION    OF    THE    MEMBRANA    TYMPANI.  789 

smooth  surface.  The  olive-tipped  bougies  are  preferable  for  diagnosing- 
and  locating  a  constriction ;  the  conical  and  cylindrical  patterns  for  making- 
applications  and  for  purposes  of  dilatation.  A  full  set  embraces  each  frac- 
tional tenth  of  a  millimeter  from  0.4  to  i  millimeter. 

When  it  is  desired  to  retain  a  bougie  for  a  considerable  time,  Mendoza's 
split  catheter  may  be  used. 


ARTIFICIAL  PERFORATION  OF  MEMBRANE  TYMPANI  AND 
MIDDLE  EAR  OPERATIONS. 

The  perforation  or  excision  of  the  membrana  tympani  by  artificial  means 
will  require  the  following: 

Speculum,  see  figures  1792  to  1797. 

Reflecting  mirror,  see  figure  1460  to  1466. 

Perforating  knife  or  needle. 

Forceps  or  hook  for  extraction  of  excised  membrane. 

Cotton  carriers  for  keeping  field  of  operation  dry. 

If  the  operation  involves  section  of  the  tensor  tympani,  the  operator  will 
require  in  addition  to  the  above : 

Knife  for  incision. 

If  the  operation  involves  mobilization  of  the  stapes,  the  additional  in- 
struments required  are : 

Small  knife  for  separating  articulation  of  the  stapes  with  the  incus. 

Double  hook  to  pass  between  the  crura  for  mobilizing  stapes. 

If  it  involves  the  extraction  of  the  stapes,  the  additional  instruments  re- 
quired are: 

Triangular  knife  for  severing  connection  with  incus. 

Curved  knife  for  separating  stapes  from  stapedius  muscle. 

Hook  for  manipulation  of  stapes. 

Forceps  for  removal  of  stapes. 

If  the  operation  involves  synechotomy  of  the  crura  of  the  stapes,  it 
will  require  in  addition  to  the  above : 

Synechotomy  knife. 

If  the  operation  is  for  the  removal  of  cholesteatoma,  the  additional  in- 
struments required  are : 

Syringe,  see  figures  1801  to  1804. 

Probe  or  hook  for  loosening  mass. 

Tympanum  tubes. 

If  the  operation  is  for  the  purpose  of  removing  granulations,  the  opera- 
tor will  require: 

Sharp  scoops. 

If  the  operation  involves  extraction  of  ossicles,  the  following  additional 
instruments  will  be  necessary : 

Snares  or  forceps  for  removal  of  ossicles,  see  figures  1849  and  1850. 

Angular  membrane  knife  for  transfixing  the  membrane. 

Angular  incus  knife  for  disarticulating  the  incus  from  the  stapes. 

Incus  hooks  for  drawing  down  the  incus. 

Bent  probe  for  manipulation  of  ossicles. 

Cotton  carriers  to  wipe  away  blood,  see  figures  1816  and  1817. 

Syringe  or  douche  with  hot  sterilized  water,  see  figures  1801  to  1804. 

The  removal  of  the  margo  tympani  may  be  secured  by  a  sharp  scoop. 
A  better  instrument,  however,  is  a  suitable  bone  gouging  forceps. 


790  AURAL    SURGERY. 

If  the  operation  necessitates  cutting  through  the  long  process  of  the  incus, 
a  special  scissors  will  be  required. 
Caries  may  be  removed  by 
Syringes,  figures  1801  to  1804. 
Probes,  figure  1834. 
Scoops,  figure  1843. 
Sequestrum  forceps. 
Bone  cutting  scissors. 

Tympanum  Perforating  Instruments. 

These  may  consist  of  needles  or  knives  according  to  the  nature  of  the 
work  in  hand.  Where  the  object  of  the  operation  is  to  relieve  confined 
pus,  puncture  with  a  lance-point  needle  will  answer,  although  a  knife  for 
incision  is  generally  preferred.  If  the  technique  involves  the  removal  of  a 
section  of  the  membrane,  a  knife  is  necessary.  Care  should  be  taken  at  all 
times  to  see  that  the  perforating  instrument  is  properly  sharpened.  Occa- 
sionally an  operator  employs  an  electro-cautery  perforator. 

Lance -Point  Needles. 

These  may  be  secured  of  various  sizes,  the  general  form  of  all  being 
the  same.  They  may  be  straight,  angular  bent,  or  bayonet  curved 


Figure  1867.    Politzer's  Tympanum  Perforator,  Straight. 


Figure  1868.    Politzer's  Tympanum  Per- 
forator, Angular. 


Politzer's  Tympanum  Perforators,  as  shown  in  figures  1867  and  1868, 
are  lance-pointed  needles  from  i^  to  2  millimeters  in  breadth,  mounted  on 
slender  shanks  and  with  suitable  handles.  They  differ  from  each  other 
only  in  that  one  variety  has  a  straight  and  the  other  an  angular  bent  shank. 


Figure  1869.    Lucae's  Perforator. 

Lucae's  Perforator,  as  portrayed  by '  figure  1869,  is  a  lance-pointed 
needle  about  i^  millimeters  in  width  with  a  long  slender  point.  The 
shaft  of  the  instrument  is  in  bayonet  form  that  the  hand  of  the  operator 
may  not  interfere  with  the  field  of  vision. 

Membrane  Perforating  Knives. 

Knives  for  perforating  the  membrane  have  been  devised  of  various 
forms  and  patterns,  some  for  simple  perforation,  others  for  removal  of  a 
section  of  the  membrane.  The  form  of  knife  selected  must  depend  on  the 
point  chosen  for  the  incision  and  the  extent  and  character  of  the  oper- 
ation. 


ARTIFICIAL    PERFORATION    OF  THE  MEMBRANA  TYMPANI. 


791 


Bishop's  Knife,  as  shown  in  figure  1870,  consists  of  a  delicate,  scalpel- 
shaped  blade  with  slender  shank  used  chiefly  for  making  sections  through 
the  posterior  fold. 

Figure  1870.    Knife  for  Separation  of  Stapes  and  Incus. 

The  Lancet-Shaped  Knife,  delineated  in  figure  1871,  is  employed  prin- 
cipally in  making  posterior  fold  openings. 


Figure  1871.    Lancet-Shaped  Knife. 

Hotz'  Tympanum  Knives,  as  shown  by  figures  1872  and  1873,  are  con- 
structed with  long,  slender,  flexible  shanks,  short  narrow  blades,  one  with 


SSI     ^ldj|JW|^j*l 


Figure  1872.     Hotz'  Round-Pointed  Knife. 


Figure  1873.     Hotz'  Sharp-Pointed  Knife. 

a  round,  smooth  point,  the  other  with  a  narrow,  sharp  point.    They  are  well 
adapted,  not  only  for  excisions,  but  for  incisions  and  various  flap  operations. 

Tympanum  Fragment  Extractor. 

This  may  comprise  a  slender,  mouse-tooth  forceps  or  a  delicate  hook 
with  a  sharp  point. 


Figure  1874.     Hook  for  Extracting 
Tympanum  Fragment. 


Figure  1875.    Bishop's  Hook  for  Extracting 
Tympanum  Fragment. 


The  Tympanum  Fragment  Hook,  pictured  in  figure  1874,  is  of  delicate 
construction,  with  a  long,  slender  shank,  terminating  in  a  hook  sharply 
recurved.  Though  usually  straight,  they  would  afford  a  better  view  if 
the  shank  were  slightly  bent. 

Bishop's  Hook  for  extracting  the  fragment  following  excision  of  the 
tympanum  differs  from  the  one  previously  described  in  being  only  slightly 
curved.  It  is  shown  in  figure  1875. 


Figure  1876.     Politzer's  Anterior  Ligament  Knife. 

Politzer's  Knife  for  making  section  of  the  anterior  ligament  of  the  mal- 
leus, as  shown  in  figure  1876,  is  slightly  curved  and  narrow,  cutting  at  its 
point  and  along  its  concave  edge.  The  breadth  of  the  cutting  surface 
should  not  exceed  2  millimeters. 


Figure  1877.     Hartmann's  Tenotomes. 


A  Tympanic  Tenotomy  may  require  special  knives,  those  with  blades 
slightly  curved  being  usually  preferred. 

Hartmann's  Tenotomes,  as  illustrated  in  figure  1877,  are  slender,  of 
delicate  construction  and  curved  both  on  the  flat  and  on  the  edge.  The 


792  AURAL    SURGERY. 

point  of  the  knife  should  reach  about  i  millimeter  farther  outward  than  its 
long  axis.     They  are  made  rights  and  lefts,  one  for  each  ear. 


Figure  1878.     Bishop's  Angular  Knives. 


Bishop's  Angular  Knives,  as  shown  by  figure  1878,  are  of  delicate  con- 
struction with  small  scalpel-shaped  blades  bent  rights  and  lefts. 

Mobilization  of  the  Stapes  requires  a  small,  curved  knife  to  separate  the 
articulation  with  the  incus.  A  fine  hook  is  then  used  to  secure  mobiliza- 
tion, or  a  special  double-pronged  hook  may  be  employed. 


Figure  1879.    Bishop's  Ossicle  Vibrator. 

Bishop's  Ossicle  Vibrator,  as  illustrated  in  figure  1879,  is  a  steel  shank 
terminating  in  a  two-pronged  fork,  the  arms  of  which  project  nearly  at 
right  angles  with  the  shaft.  The  outer  arm  is  curved  on  the  edge  and 
bent  outward.  The  instrument  is  used  to  grasp  the  handle  of  the  malleus 
or  arch  of  the  stapes  and  thus  forcibly  move  it  with  a  view  of  breaking  up 
adhesions. 

Knife  for  Synechotomy  of  the  Crura. 

Politzer's  Synechotomy  Knife,  displayed  in  figure  1886,  has  a  blade  only 
y2  millimeter  broad,  i  millimeter  long,  and  with  a  projection  at  right 


Figure  1886.    Politzer's  Synechotomy  Knife. 

angles  on  one  side  i  millimeter  from  the  point.  This  latter  feature  is  in- 
tended to  prevent  the  blade  of  the  knife  from  passing  through  the  orbicu- 
lar ligament  into  the  vestibule. 

Tympanic  Tubes. 

These  are  employed  for  the  removal  of  cholesteatomata,  for  which  pur- 
pose they  are  attached  to  a  suitable  syringe.     They  may  be  of  elastic  web, 


Figure  1887.     Politzer's  Straight  Tympanic  Tube. 


Figure  1888.    Politzer's  Curved  Tympanic  Tube.  Figure  1889.    Hartmann's  Canula. 

hard  rubber  or  metal.  If  of  the  latter,  silver  is  to  be  preferred.  Slender 
tubes  will  be  found  useful  for  this  purpose,  because  when  attached  to  a 
syringe  a  stream  of  water  may  be  brought  to  bear  directly  upon  the  de- 
sired point.  Furthermore,  in  certain  cases  they  can  be  introduced 


TYMPANIC    TUBES.  793 

through  a  narrow  canal  where  an  ordinary  syringe  pipe  would  not 
enter.  They  are  advised  by  Jack  for  treating  chronic  inflammation  of  the 
attic  space.  They  may  be  used  to  advantage  with  a  syringe  of  the  Anel 
type. 

Politzer's  Tympanic  Tubes,  as  shown  in  figures  1887  and  1888,  differ 
from  each  other  only  in  their  form.  They  are  of  elastic  web,  soft  and  flex- 
ible to  facilitate  their  introduction  into  a  tortuous  canal. 

Hartmann's  Canula,  as  depicted  in  figure  1889,  consists  of  a  slender 
hard  rubber  tube  with  slightly  bulbous  tip.  It  may  be  attached  to  almost 
any  form  of  syringe  or  douche. 

Probes. 

These  are  required  in  some  cases  for  loosening  masses,  exploring  dis- 
eased tracts  and  general  manipulation  of  small  parts.  They  are  usually  soft 
and  flexible  that  they  may  be  curved  in  any  desired  form. 


Figure  1890.     Hotz'  Ear  Probe. 

Hotz'  Ear  Probe,  represented  in  figure  1890,  does  not  differ  from  those 
employed  in  general  surgery  excepting  that  it  is  made  from  a  smaller  wire. 
It  is  usually  about  4  inches  in  length. 

Scoops. 

These  are  required  for  removing  granulations  and  in  various  middle  ear 
affections.  They  consist  of  minute  bowl-shaped  instruments,  usually  with 
sharp  edges. 


Figure  1891.     Politzer's  Sharp  Scoops. 

Politzer's  Sharp  Scoops,  as  traced  in  figure  1891,  consist  of  small  circu- 
lar steel  scoops  3,  4,  and  5  millimeters  in  external  diameter,  respectively. 
The  two  larger  are  perforated  at  the  back  of  the  bowl  in  curette  form.  A 
similar  pattern  designed  by  Wolff  is  constructed  with  a  malleable  shank 
that  it  may  be  bent  into  any  desired  shape. 

Incus  Hooks. 

These  are  slender  probe-like  instruments,  angular  bent.  They  are  em- 
ployed in  many  operations  for  drawing  down  the  small  bones. 


Figure  1892.    Ludwig's  Incus  Hooks. 

Ludwig's  Incus  Hooks,  as  seen  by  consulting  figure  1892,  are  small, 
slender  and  bent  at  right  angles  to  the  shaft,  the  bent  portion  being  5  mil- 
limeters long  and  2  millimeters  in  breadth.  They  are  manufactured  in 
rights  and  lefts,  one  for  each  ear. 

Marge  Tympani  Gouges. 

These  may  be  of  the  plain  patterns  used  in  opening  the  mastoid  process, 
or  in  forceps  form. 


794 


AURAL    SURGERY. 


Politzer's  Bone  Gouging  Forceps,  the  action  of  which  is  made  clear  in 
figure  1893,  are  particularly  adapted  for  removing  pieces  of  bone  from  the 
outer  wall  of  the  attic.  They  practically  consist  of  a  sliding  chisel  operated  by 
a  forceps  handle.  One  arm  of  the  forceps  is  bent  at  an  angle  of  90°  with 


Figure  1893.    Politzer's  Bone  Gouging  Forceps. 

the  axis  of  the  instrument,  the  tip  being  curved  upward  at  a  sharp  angle. 
Attached  to  the  opposite  forceps  blade,  and  sliding  in  close  contact  with 
the  bent  blade,  is  a  sharp-pointed  chisel,  so  arranged  that  any  substance 
grasped  between  the  point  of  the  chisel  and  the  curved  tip  may  be  severed 
by  closing  the  handles  of  the  instrument. 

Anvil  Bone  or  Incus  Scissors. 

These  instruments  have  sharp,  strong  blades  mounted  on  long,  slender 
shanks.  They  are  employed  for  cutting  through  the  long  processes  of  the 
incus. 


Figure  1894.    Politzer's  Anvil  Bone 
Scissors  and  Forceps. 

Politzer's  Anvil  Bone  Scissors  and  Forceps,  as  may  be  seen  by  consult- 
ing figure  1894,  consist  of  a  delicate  pair  of  scissors  operated  by  mechanism 
of  peculiar  design.  One  blade  of  the  scissors  is  fixed,  forming  an  exten- 
sion of  the  canula.  The  latter  is  attached  at  an  obtuse  angle  with  the  scissors 
handle.  The  moving  blade  of  the  scissors  is  attached  to  the  fixed 
blade  of  the  instrument  by  a  slender  shaft  passing  within  the  canula.  As 
found  in  the  market,  it  is  usually  in  combination  with  a  forceps  having  alli- 
gator-shaped jaws. 


HEARING    INSTRUMENTS. 


Sequestrum  Forceps. 


795 


These  need  not  differ  from  many  patterns  of  delicate  dressing  or  fine 
hemostatic  forceps.  They  are  employed  to  remove  bone  sequestra  from 
the  external  meatus. 


Figure  1895.    Sequestrum  Forceps. 

The  Sequestrum  Forceps,  exhibited  in  figure  1895,  are  similar  in  design 
to  many  patterns  of  hemostatic  forceps.  They  should  have  strong  jaws 
with  a  limited  breadth  and  good  grasping  power. 

Sequestrum  Scissors. 

Bone  cutting  scissors  should  consist  of  strong  yet  small  instruments 
designed  for  cutting  through  bone  sequestra. 


Figure  1896.    Politzer's  Bone  Scissors. 

Politzer's  Bone  or  Sequestrum  Scissors,  as  illustrated  in  figure  1896,  are 
short,  angular-bent  and  of  strong  construction.  They  are  usually  about  5 
inches  in  length. 

HEARING  INSTRUMENTS. 

These  consist  of  devices  employed  to  collect  sound  waves,  concentrate 
them  on  the  membrana  tympani,  and  thus  render  them  more  intelligible  to 
a  diseased  ear.  Their  value  depends  on  proper  construction,  both  in  the 
collection  and  conduction  of  the  sound  waves.  Various  appliances  are  em- 
ployed, depending  upon  the  condition  of  the  patient  and  the  circum- 
stances under  which  the  instruments  are  to  be  used. 

Those  commencing  the  use  of  hearing  instruments,  especially  of  trum- 
pets and  auricles,  will  frequently  be  disappointed  at  first  and  will  complain 
that  sounds  are  confused;  but  after  a  short  experience  they  will  usually  ap- 
pear natural,  and  the  assistance  derived  will  be  so  highly  valued  that  the 


796 


AURAL    SURGERY. 


use  of  artificial  aids  will  not  be  willingly  dispensed  with.  The  most  effective 
of  these  collectors  and  conductors  are  those  known  as  conversation  tubes. 
They  can  not  be  employed,  however,  for  any  except  close  range  speak- 
ing, or  conversation  between  individuals. 

Conversation  Tubes. 

These  consist  of  a  spiral  wire  tube  covered  with  some  woven  fabric,  pro- 
vided at  one  end  with  a  funnel  or  cup-shaped  mouth-piece,  and  at  the  other 
with  an  ear-piece  of  such  shape  that  it  will  rest  lightly  within  the  external 
auditory  canal.  Usually  a  curved  olive-shaped  tip  is  preferred,  although 
straight  ones  are  sometimes  used. 

When  in  use,  the  mouth-piece  should  be  held  close  to  the  lips  of  the 
speaker.  Loud  talking  through  these  tubes  is  unnecessary;  in  fact,  it  con- 
veys such  an  unpleasant  sensation  to  the  hearer  that  it  is  not  permissible. 

Low  conversational  tones  in  most  cases  are  clearly  understood.  When 
in  service,  the  tubes  may  be  worn  around  the  neck,  under  the  coat  or  cloak 
or  rolled  up  and  carried  in  a  pocket.  They  are  constructed  in  two  forms, 
known  as  straight  and  conical.  In  the  first  the  tube  is  of  the  same  diam- 
eter throughout  its  entire  length.  In  the  latter  the  tube  is  conical  in  form, 
thus  further  concentrating  the  waves  collected  by  the  funnel-shaped  mouth- 
piece. This  class  of  hearing  instruments  is  best  adapted  for  extreme  cases 
and  for  use  among  friends  and  members  of  a  family,  or  for  business  men 
who  do  not  wish  others  to  overhear  their  conversation.  Owing  to  their  lack 
of  concentrating  powers,  their  principal  value  being  in  conducting,  they  do 
not  answer  well  for  public  speaking  or  for  hearing  a  general  conversation. 


Figure  1897.    Conical  Conversa- 
tion Tube. 


Figure  1898.     The  Otophone  Conversation  Tube. 


The  Conical  Conversation  Tube,  shown  in  figure  1897,  exhibits  the  form 
of  tube  ordinarily  employed.  Usually  they  are  about  3  feet  in  length,  al- 
though tubes  4  and  5  feet  in  length  are  preferred  by  some  patients.  They 
may  be  obtained  covered  with  worsted,  mohair  or  silk,  the  latter  being 
generally  selected.  Dark  colors  are  preferable  to  light  or  bright  ones,  as 
they  do  not  attract  as  much  attention. 

The  Otophone  Conversation  Tube,  as  depicted  in  figure  1898,  is  a  large 
sized  conversation  tube,  the  aural  end  of  which  is  provided  with  a  dia- 
phragm by  which  augmentation  of  the  sound  waves  is  secured.  The 
vibrator  employed  is  similar  to  those  used  in  the  construction  of  the  tele- 
phone. It  secures  clearness  in  voice  tones  and  at  the  same  time  avoids 
confusing  reverberations.  By  consulting  the  illustration  referred  to,  it 
will  be  seen  that  the  instrument  is  placed  against  the  ear  and  not  inserted 
into  the  auditorv  canal. 


HEARING    INSTRUMENTS. 


Ear  Trumpets. 

Ear  trumpets  are  designed  particularly  for  the  concentration  of  sound 
waves.  The  constant  demand  for  smaller  instruments  has  induced  makers 
in  many  instances  to  sacrifice  efficiency  for  size,  a  matter  to  be  regretted. 
Patients  should  insist  on  having  the  best  appliance  regardless  of  size. 
They  may  be  obtained  in  many  patterns  constructed  from  metal,  rubber 
or  celluloid,  the  latter  being  but  little  employed.  Metal,  although  almost 
universally  accepted,  is  objectionable  because  of  a  peculiar  metallic  ring 
imparted  to  the  sound  waves.  Hard  rubber,  when  used  in  the  construction 
of  these  instruments,  is  free  from  these  objections,  but  the  appliances  are 
fragile  and  easily  broken.  While  many  forms  of  these  instruments  may 
be  found  in  the  market,  the  better  patterns  are  either  funnel-shaped  or 
paraboloid. 


Figure  1899.     Dipper  Trumpet. 


Figure  1900.    Pocket  Trumpet. 


The  Dipper  Trumpet,  as  it  appears  in  figure  1899,  is  a  cup-shaped  bowl 
4  to  5  inches  in  diameter  at  the  base  and  2^  to  3  inches  in  diameter  at  the 
bottom.  The  bowl  is  provided  with  a  side  opening  that  connects  with  a 
conical- shaped  pipe  12  inches  or  more  in  length  with  a  suitable  ear-piece. 
A  flange-like  projection  extending  from  the  wall  of  the  cup  upon  one  side 
nearly  to  the  opposite  wall,  collects  the  sound  waves  from  the  bottom  of  the 
cup  reflecting  them  by  its  peculiar  shape  into  and  through  the  side  open- 
ing. This  pattern  is  one  of  the  most  effective  of  this  class  of  instru- 
ments. They  are  disadvantageous  because  of  their  great  bulk,  and  for  this 
reason  are  seldom  employed. 

The  Pocket  Trumpet,  illustrated  in  figure  1900,  consists  of  a  shallow 
bowl,  one-half  of  which  is  covered  with  a  bridge  identical  in  form 
with  the  under  or  sounding  surface.  The  bowl  is  circular  in  shape  with 
doubly  convex  sides.  A  jointed  tube  terminating  in  an  ear-piece  is  at- 
tached at  the  side  and  in  the  center  of  the  covered  section.  The  regular 
pattern  is  about  5  inches  in  diameter  and  from  1^2  to  2  inches  in  thickness, 
and  can  be  easily  carried  in  the  pocket. 


Figure  1901.    Jointed  Ear  Trumpet. 


Figure  1902.     Bugle  Trumpet. 


The  Jointed  Ear  Trumpet,  as  may  be  seen  by  referring  to  figure  1901, 
consists  of  a  small,  shallow  bowl,  usually  from  3  to  4  inches  in  diameter, 
connected  by  means  of  several  fixed  joints  with  a  conical  tube  and  suitable 
ear-piece.  They  are  usually  made  in  three  sizes,  varying  from  13  to  18 
inches  in  extreme  length. 


798 


AURAL    SURGERY. 


The  Plain  Bugle  Trumpet,  as  illustrated  by  figure  1902,  differs  from 
the  pattern  last  described  principally  in  the  shape  of  the  conducting  tube, 
which  in  this  instrument  is  bent  by  oblique  angles  into  a  bugle  form.  The 


Figure  1903.    London  Hearing  Horn. 


Figure  1904.     Otophone  Trumpet. 


instrument  is  compact  and  better  fitted  for  carrying  than  the  previously 
described  patterns.  The  width  of  the  flange  varies  from  3  to  4  inches  and 
the  length  of  the  instrument  from  4  to  5  inches. 

The  London  Hearing  Horn,  as  disclosed  in  figure  1903,  is  a  small,  cup- 
shaped  bowl  provided  with  mechanism  peculiarly  adapted  for  the  concen- 
tration and  conduction  of  such  sound  waves  as  the  bell-shaped  opening  is 
able  to  collect.  A  perforated  diaphragm  across  the  front  of  the  instrument 
admits  the  sound  waves,  while  a  tube  having  its  cup-shaped  opening  tow- 
ard the  back  or  base  of  the  bowl  conducts  the  sound  from  the  collecting 
bell  to  the  ear.  These  instruments,  owing  to  their  small  size  and  compact 
form,  are  the  most  popular  of  all  devices  of  this  class.  They  may  be  pro- 
cured in  sizes  varying  from  \y2  to  2^  inches  in  diameter.  They  are  man- 
ufactured both  nickel-plated  and  of  a  "dead"  black,  the  latter  being  more 
popular  because  less  conspicuous. 

The  Otophone  Trumpet,  exhibited  in  figure  1904,  is  constructed  with  an 
aural  terminal  similar  to  the  conversation  tube  displayed  in  figure  1897. 
It  is  provided  with  a  bell-shaped  mouth  that  serves  as  a  good  collector  of 
the  sound  waves.  The  apparatus  is  small,  may  be  easily  carried,  and  is 
well  adapted  for  hearing  public  conversation. 


Figure  1906.    Ear  Cornets.  Figure  1908.    Audiphone. 

The  Ear  Cornets,  as  illustrated  in  figure  1906,  are  among  the  smallest 
of  hearing  instruments.  They  are  constructed  of  silver  and  are  efficient 
only  in  cases  of  obstruction  of  the  meatus  by  reason  of  contraction  or  the 
presence  of  polypi. 


HEARING    INSTRUMENTS.  799 

Rhodes'  Audiphone  consists  of  a  thin,  elastic,  hard  rubber  plate  em- 
ployed to  convey  sound  to  the  auditory  nerve  through  the  medium  of  the 
teeth.  It  is  fan-shaped,  and  when  adjusted  for  hearing,  is  placed  in  a  state  of 
tension,  contact  being  made  with  one  or  more  of  the  upper  teeth  only.  By 
means  of  a  series  of  cords  exhibited  in  the  illustration  (see  figure  1908),  the 
plate  may  be  curved  or  drawn  taut,  in  which  condition  it  will  serve  the 
purposes  of  many  patients.  While  many  have  been  able  to  use  this  appli- 
ance with  great  satisfaction,  it  is  applicable  only  in  certain  classes  of  cases. 
To  just  what  forms  of  disease  the  instrument  may  be  applied  with  success, 
we  are  unable  to  state  actual  tests  having  thus  far  been  the  only  means 
of  determination. 

Artificial  Tympana. 

These  consist  of  one  or  more  thin  elastic  discs,  placed  within  the  exter- 
nal auditory  canal  and  retained  by  lateral  pressure  upon  the  meatus  walls. 
They  are  introduced  and  withdrawn  either  by  a  wire  permanently  attached 
or  by  a  probe  and  well-secured  thread.  Many  patterns  are  to  be  found,  and 
each  patient  should  be  given  an  opportunity  to  try  several  different  designs, 
that  the  one  may  be  selected  which  will  afford  the  greatest  amount  of  relief. 


Figure  1909.    Toynbee's  Artificial  Tympanum.  Figure  1910.    Field's  Artificial  Tympanum. 

Toynbee's  Artificial  Tympanum,  as  pictured  in  figure  1909,  is  a  soft  rub- 
ber circular  disc  about  6  or  7  millimeters  in  diameter,  in  the  center  of  which 
one  end  of  a  short  silver  wire  is  securely  fastened.  The  length  of  the  wire 
should  correspond  to  the  depth  of  the  meatus.  The  proximal  end  is  curved, 
forming  a  small  loop,  thus  supplying  a  handle  for  introduction  and  with- 
drawal. Thread  has  been  advised  for  this  purpose,  but  experience  has 
demonstrated  that  the  use  of  a  thread  does  not  permit  of  as  firm  contact  of 
the  disc  with  the  meatus  wall,  and  further,  that  the  threaded  discs  are  more 
liable  to  become  displaced.  Care  must  be  exercised  in  the  manufacture  of 
this  appliance,  to  see  that  the  wires  are  firmly  attached  to  the  disc,  that 
separation  may  not  take  place.  Some  objection  has  been  made  to  this  de- 
sign, on  the  plea  that  when  the  jaw  is  articulated,  a  rattling  or  crackling 
sound  is  produced  by  the  movement  of  the  meatus  walls  against  the  disc. 

Field's  Artificial  Tympanum,  as  shown  in  figure  1910,  is  a  double  disc, 
both  faces  of  which  are  made  from  fine  flannel,  the  space  between  them 
being  filled  with  absorbent  cotton. 


CHAPTER  XXX 


OPHTHALMIC   SURGERY. 

While  in  operations  on  the  eye  the  same  precautions  that  govern  the 
principles  of  aseptic  surgery  must  be  closely  adhered  to,  still  greater  care 
should  be  exercised  in  the  selection  and  preparation  of  all  necessary  instru- 
ments, particularly  those  with  cutting  edges  or  sharp  points. 

Not  only  must  such  instruments  be  carefully  ground  and  sharpened,  but 
every  precaution  should  be  taken  to  see  that  they  are  not  damaged  during 
the  process  of  cleansing  and  sterilizing. 

If  boiled  in  water,  eye  instruments  should  be  placed  in  some  such  form 
of  rack,  as  outlined  in  figure  327,  that  the  motion  of  the  bubbling  water 
may  not  injure  the  edges  and  points,  by  bringing  them  in  contact  with  each 
other  or  the  vessel  containing  them. 

After  sterilizing  it  is  advised  that  the  instruments  be  stored  in  a  shallow 
dish  of  alcohol.  Immediately  before  use  they  should  be  wiped  with  a  soft 
cloth  saturated  with  alcohol,  after  which  they  should  be  rinsed  in  sterilized 
water  or  sterile  normal  salt  solution,  in  order  to  dilute  or  entirely  remove 
the  alcohol. 

Before  sterilization,  knives,  needles,  forceps,  scissors,  etc.,  should  be 
carefully  examined  with  a  magnifying  lens,  to  see  that  they  are  not  only 
free  from  rust  and  foreign  matter,  but  that  the  edges  and  points  are  in  good 
order.  The  latter  should  be  tried  on  a  test  drum,  similar  to  that  portrayed 
in  figure  603,  and  all  that  perforate  the  skin  with  a  click  should  be  rejected 
or  sharpened.  Turned  points  are  not  always  evidence  of  poor  instruments; 
they  may  often  be  straightened  by  slight  pressure  on  the  ringer  nail.  Scis- 
sors should  be  tested  by  cutting  cotton  or  wet  tissue  paper.  Such  instru- 
ments should  cut  well  at  the  points,  and  the  blades  should  not  over-ride  or 
pass  by  each  other. 

Many  oculists  employ  black  iron-dyed  sutures  for  operations  in  and  about 
the  eye,  for  being  fine,  they  are  not  otherwise  easily  distinguished. 

Dressings  usually  consist  of  a  small  piece  of  gauze  or  lint  folded  and  laid 
upon  the  eyelid,  over  which  a  layer  of  absorbent  cotton  is  held  in  place 
with  either  a  roller  bandage  or  a  strip  of  isinglass  plaster.  The  bandage,  if 
employed,  may  be  either  muslin  or  gauze,  the  latter  being  preferred  for 
use  in  hot  weather. 

The  instruments  employed  in  examinations  and  operations  on  the  eye 
may  be  classified  as  those  for  iridectomy,  cataract,  staphyloma,  tatooing  the 
cornea,  paracentesis,  evisceration  or  exenteration,  enucleation,  pterygium, 
strabismus  by  tenotomy,  strabismus  by  advancement,  entropium,  trachoma, 
ptosis,  tarsorrhaphy,  canthoplasty,  trichiasis,  chalazion  cysts,  extraction  of 
foreign  bodies,  disease  of  lachrymal  duct  and  sac  and  examinations,  in  addi- 
tion to  a  small  list  available  for  general  use. 

800 


OPERATIONS    IN    THE    HOSPITAL.  801 


OPERATIONS  IN  THE  HOSPITAL. 

These  will  require  the  following  list  of  instruments,  appliances,  etc  : 

Furniture. 

Operating  table,  figures  178  to  191. 
Table  cover. 

Dressing  table,  figures  204  to  206. 
Instrument  table,  figures  209  to  211. 
2  Wash  stands  and  bowls,  figures  215  to  220. 
Slop  jar,  figures  239  to  241. 

2  Trays  for  instruments,  sutures,  etc.,  figures  242  to  245. 
Small  steam  sterilizer,  figures  307  to  322. 
Small  hot  water  sterilizer,  figures  314  and  315. 

General  Appliances,  Dressings,  Etc. 
Electric  battery,  figures  446  to  459. 
Stomach  pump  or  tube,  figures  1643  and  1662. 
Hypodermic  syringes,  figures  360  to  370. 
Fever  thermometer,  figures  74  to  80. 
Surgical  soap,  figure  274. 
Nail  cleaner,  figures  283  to  285. 
2  Hand  brushes,  figure  277. 
Irri gator,  figures  224  to  238. 

Supply  of  hot  and  cold  sterilized  water,  figures  314  and  315. 
Sheets. 
Towels. 

Sponges,  small  (or  substitutes),  figures  685  to  689. 
Surgeon's  apron,  figure  266. 
Absorbent  gauze,  figure  791. 
Absorbent  cotton,  figure  795. 
Isinglass  plaster  or  muslin,  figure  790. 
Roller  bandages,  figures  796  to  798. 
Safety  pins,  figures  802  and  803. 

Medicines,  Etc. 

Sol.  Bichloride  of  mercury,   i  to    5,000. 

i  "   10,000. 

Atropine,  i  "         120. 

Eserine,  i  "     1,000. 

Cocaine,  i  "          25. 

Boric  acid,  saturated. 

Salt,  normal. 

Carbolic  acid,  i  to        20. 

lodoform,  finely  powdered. 
Collodion. 
Alcohol. 

Aromatic  spirits  of  ammonia.    - 
Liquor  morphine  sulphate. 
Whisky  or  brandy. 
Teaspoon. 
Tablespoon. 
Tumbler. 
Feeding  Tube. 
Tablets  Strychnine  Sulphate. 

si  COLLEGE   01-- 

l-K\£i  SU 


802  OPHTHA1MIC  SURGERY. 

If  Anesthesia  is  to  be  employed: 

Ether,  or 

Chloroform. 

Inhaler,  ether  or  chloroform,  figures  329  to  338 

Mouth  gag,  figures  346  to  349. 

Tongue  forceps,  figures  343  to  345. 

OPERATIONS  OUT   OF  HOSPITAL. 

Furniture  and  Supplies  to  be  Provided  at  Residence. 
Plain  table. 

Table  cover,  consisting  of  two  folded  blankets,  sheet  and  rubber  cloth. 
Dressing  and  instrument  table. 
Wash  stand  with  bowls. 
Slop  jar. 
Alcohol. 

Whisky  or  brandy. 
Teaspoon. 
Tablespoon. 
Tumbler. 
Boiled  water  in  same  vessel  in  which  it  was  heated. 

General  Appliances,  Dressings,  Etc.,  to  be  Provided  by  Surgeon. 
Irrigator,  figures  693  to  696. 
Hypodermic  syringe,  figures  360  to  370. 
Fever  thermometer,  figures  74  to  80. 
Surgical  soap,  figure  274. 
2  Hand  brushes,  figure  277. 
Nail  cleaner,  figures  283  to  285. 
Towels. 

Sponges,  small  (or  substitutes),  figures  685  to  689. 
Surgeon's  apron,  figure  266. 
Absorbent  gauze,  figure  791. 
Absorbent  cotton,  figure  795. 
Isinglass  plaster  on  muslin,  figure  790. 
Roller  bandages,  figure  796  to  798. 
Safety  pins,  figures  802  and  803. 

Medicines. 
Tablets  Bichloride  mercury. 

Atropine. 

Eserine. 

Cocaine. 

Strychnine. 

Boric  acid. 

Morphine  Sulphate. 
Carbolic  acid,  95  per  cent, 
lodoform,  finely  powdered. 
If  Anesthesia  is  to  be  employed: 
Ether. 

Ether  inhaler,  figures  332  to  338. 
Chloroform. 

Chloroform  inhaler,  figures  329  to  331. 
Mouth  gag,  figures  346  to  349. 
Tongue  forceps,  figures  343  to  345. 
-  0   B  FJ  H  J  J  0  0 


GENERAL    INSTRUMENTS.  803 


GENERAL   INSTRUMENTS. 

Ophthalmic  surgery  necessitates  the  use  of  but  few  general  instruments, 
the  following  brief  list  including  all  that  should  be  enumerated  under  this 
head: 

Specula  for  separating  the  lids 

Lid  elevators  for  raising  or  lifting  the  lid  from  the  conjunctiva. 

Dressing  forceps. 

Small  needles  for  suturing. 

Needle  holder. 

Silk  (black  generally  preferred),  figures  717  to  727. 

Catgut,  figures  708  to  713. 

Syringe  for  irrigation,  figures  693  to  696. 

Droppers,  figures  in  and  112. 

Specula. 

A  speculum  for  separating  the  eyelids  should  be  capable  of  adjustment 
to  different  widths,  and  in  each  case  to  which  it  is  applied,  it  should  be  spread 
to  the  maximum.  It  must  be  so  shaped  as  not  to  press  upon  the  globe,  the 
blades  should  open  as  nearly  parallel  as  possible,  be  out  of  the  way  of  the 
operator,  fit  closely  to  the  contour  of  the  face,  and,  except  for  special  cases, 
the  frame- work  or  mechanism  should  project  toward  the  outside;  that 
is,  away  from  the  nasal  margin  of  the  eye.  Two  sizes  should  be  pro- 
vided, for  adults  and  children.  Nearly  all  are  constructed  from  steel  wire, 
neatly  polished  and  nickel-plated.  All  should  be  manufactured  with  even 
surfaces,  smooth  curves  and  well-rounded  tips,  that  the  conjunctiva  may  not 
be  injured  by  their  application.  Among  the  large  number  of  patterns  now 
in  the  market,  the  most  of  which  vary  only  in  the  method  of  adjustment, 
we  illustrate  the  following: 


Figure  1911.     Plain  Speculum.  Figure  1912.    Von  Graefe's  Speculum. 

The  Plain  Eye  Speculum,  as  traced  in  figure  1911,  consists  of  a  single 
piece  of  wire,  the  center  of  which  forms  a  small  circle,  so  adjusted  as  to 
form  the  spring  or  separating  power  of  the  blades.  The  terminal  portions 
of  each  end  are  curved  in  such  a  manner  as  to  form  a  double  retractor, 
pressing  backward  and  outward  upon  the  exposed  folds  of  the  lids. 

Midway  in  the  shaft  of  each  blade  the  instrument  is  bent  outward  at  an 
angle  of  about  45  °,  these  projections  serving  as  points  of  contact  for  the 
finger  tips  when  pressing  the  blades  together. 

This  instrument  possesses  no  advantage,  excepting  that  it  can  be  pro- 
cured at  a  low  price.  The  usual  length  is  about  3  inches,  while  the  wire  used 
should  not  be  less  than  No.  14,  Brown  &  Sharp's  gauge. 


804 


OPHTHALMIC  SURGERY. 


Von  Graefe's  Speculum,  as  depicted  in  figure  1912,  is  similar  in  con- 
struction tc  the  plain  speculum.  It  is  curved  through  its  center  portion  so 
as  to  incline  toward  the  temporal  bone  when  in  use  and  at  its  nasal  extrem- 
ities to  fit  closely  under  the  eyelids.  The  lids  are  held  apart  by  the  re- 
siliency of  the  spring,  which  forms  the  base  of  the  instrument.  A  ratchet 
and  set  screw  placed  near  the  junction  of  the  outer  and  middle  thirds,  enable 
the  operator  to  fix  the  blades  after  the  dilatation  desired  has  been  secured. 
Cup-shaped  attachments  near  the  center  of  each  blade  enable  the  operator 
to  secure  a  firm  hold  on  the  instrument.  This  is,  we  believe,  the  most  popu- 
lar pattern  among  operators  generally.  Like  the  majority  of  instruments 
of  this  class,  it  may  be  used  either  right  or  left.  The  length  is  usually 
about  3^  inches. 


Figure  1913.    Stevens' Speculum.  Figure  1911.    Luer's  Improved  Speculum. 

Stevens'  Speculum,  as  indicated  in  figure  1913,  resembles  the  ordinary 
spring  pattern  in  general  form,  its  main  body  being  slightly  curved  down- 
ward on  the  flat.  The  blades  are  of  tortoise  shell  and  trough-shaped,  with 
faces  bending  upward.  It  is  claimed  that  the  pressure  of  the  solid  plate  of 
shell  is  less  disagreeable  than  that  caused  by  the  bent  wires  commonly  em- 
ployed in  eye  specula.  Near  the  center  of  each  branch  a  small  cup-shaped 
finger-piece  serves  as  the  holder.  The  instrument  is  of  light  construction 
and  easily  manipulated. 

Luer's  Improved  Speculum,  as  shown  in  figure  1914,  consists  of  two 
slender  shafts,  each  provided  with  a  cross-bar  which  projects  inward,  so  that 
they  rest  one  over  the  other.  The  ends  of  the  shafts  are  fashioned  into 
slender  fenestrated  blades,  sharply  re-curved  downward  on  the  edge. 
Ear-shaped  sections  projecting  upward  serve  as  finger-pieces.  The  exten- 
sion is  maintained  by  a  delicate  coiled  wire  spring  that  encircles  both  cross- 
bars serving  to  keep  them  separated.  The  outer  cross-bar  on  its  proximal 
side  is  transversely  serrated,  the  teeth  serving  to  keep  the  blades  from  slip- 
ping under  the  force  of  the  lids.  This  extension  is  released  when  inward 
pressure  is  made  on  the  handles  or  shaft  tips.  With  this  instrument  any 
required  amount  of  dilatation  may  be  secured. 


^^"^^^^  .  ^  — 

Figure  1915.    Noyes'  Speculum.  Figure  1916.    Luer's  Original  Speculum. 

Noyes'  Speculum,  as  disclosed  by  figure  1915,  is  a  flattened  U-shaped 
bar  terminating  in  round  wire  tips  similar  to  those  previously  described,  ex 


uacu.    uy     uguie    1915,    is>    a.  uctLLcucu   u -OLIO. 

ua.r  iciimuiumg  in  rouuu  wire  tips  similar  to  those  previously  described,  ex 
cepting  that  the  points  of  the  tips  are  curved  in  a  small  circle  to  avoid  injur- 

inor  tViP>   cr>ft   l"iccii<ic 


ing  the  soft  tissues. 


GENERAL    INSTRUMENTS.  805 

While  the  spring  of  the  flattened  bar  above  referred  to  tends  to  separate 
the  blades,  the  adjustment  is  controlled  by  a  toggle-joint  manipulated  by 
a  set  screw,  so  that  any  degree  of  separation  may  be  secured  and  perma- 
nently maintained.  Small  cup-shaped  pieces  attached  to  the  outer  margin 
of  the  arms  furnish  means  by  which  a  firm  grasp  on  the  instrument 
may  be  secured.  The  total  length  is  about  3^  inches,  and  the  general 
form  of  the  instrument  is  nearly  straight. 

Luer's  Original  Speculum,  as  set  forth  in  figure  1916,  differs  from  the 
pattern  of  Von  Graefe  in  being  shorter,  more  delicate,  and  in  having  blades 
that  are  more  sharply  curved  on  the  flat. 

Lid  Elevators. 

These  are  practically  a  form  of  curved  retractor.  They  are  used  to  ele- 
vate and  hold  the  lids  away  from  the  globe.  They  are  useful  for  inspecting 
the  cornea  and  conjunctiva  and  may  at  times  be  employed  in  place  of  an  eye 
speculum,  either  for  children  or  nervous  patients  to  whom  a  fixed  instrument 
might  be  unbearable  In  the  absence  of  a  lid  elevator  a  strabismus  hook 
may  be  used  for  this  purpose. 


Figure  1917.     Desmarre's  Lid  Elevator.  Figure  1918.    Stevens'  Lid  Elevator. 

Desmarre's  Lid  Elevator,  as  shown  in  figure  1917,  consists  of  a  shallow 
spoon-shaped  blade,  sharply  curved  on  the  convex  side.  The  better  patterns 
are  manufactured  from  German  silver.  They  may  be  usually  obtained 
in  four  sizes,  each  10,  12,  14  and  16  millimeters  in  width  respectively. 

Stevens'  Lid  Elevator,  as  illustrated  in  figure  1918,  differs  from  the  pat- 
tern of  Desmarre,  in  being  smaller,  more  delicate  and  made  from  tortoise 
shell. 


GTIEMANN&CO. 


Figure  1919.     Noyes'  Lid  Elevator.  Figure  1920.    Desmarre's  Jointed 

Lid  Elevator. 

Noyes'  Lid  Elevator,  as  pictured  in  figure  1919,  is  constructed  from  steel 
wire,  the  retracting  parts  or  contact  surfaces  of  which  correspond  somewhat 
to  the  outlines  of  the  pattern  of  Desmarre.  Its  inventor  claims  that  it  is  so 
shaped  as  to  expose  the  globe  to  the  greatest  possible  degree,  pressing  the 
lid  far  under  the  orbital  roof,  without  making  pressure  on  or  even  touching 
the  ball. 

Desmarre's  Jointed  Lid  Elevator,  portrayed  in  figure  1920,  consists  of 
two  elevators  of  the  Desmarre  pattern,  with  short  shanks  united  with  a 
hinged  joint.  Its  advantages  consist  in  furnishing  two  sizes  in  compact 
form.  They  are  so  arranged  that  when  closed,  they  rest  one  within  the  other. 

Dressing  Forceps. 

These  consist  of  delicate  fine-pointed  forceps,  with  serrated  jaws 
employed  for  the  removal  of  foreign  bodies,  as  cotton  holders,  and  in  some 
operations  on  the  iris. 


806 


OPHTHALMIC  SURGERY. 


The  Dressing  Forceps,  shown  in  figures  1921  and  1922,  differ  only  in  the 
shape  of  the  jaws,  which  in  one  pattern  are  straight  and  in  the  other  sharply 
curved.  Generally,  these  are  transversely  serrated  with  fine  teeth. 


Figure  1921.     Straight  Dressing  Forceps. 


Figure  1922.    Curved  Dressing  Forceps. 

Needles. 

Needles  for  operations  on  the  eye,  while  usually  of  the  ordinary  surgical 
patterns,  must  be  of  the  finest  possible  quality,  carefully  pointed  and 
sharpened.  Those  in  common  use  are  usually  half  or  full  curved  and  vary 
in  size  from  Nos.  20  to  36. 


TKUAX-GREtNE-Ct. 

Figure    1923.      Full 
Curved  Needles. 


TRUAX-GREENE-CO. 

Figure    1924.      Half 
Curved  Needles. 


T"UAX-GREENE-CO. 


Figure  1925.    Full  Curved    Figure  1926.    Half  Curved 
Spring  Eye  Needles.  Spring  Eye  Needles. 


The  Surgical  Needles,  shown  full  size  in  figures  1923  and  1924,  are  of 
the  ordinary  surgical  patterns. 

The  Spring  Eye  Needles,  outlined  by  figures  1925  and  1926,  are  of  the 
pattern,  shown  in  figure  749,  in  connection  with  which  they  are  fully  de- 
scribed. They  are  shown  full  size  in  the  illustrations. 


Needle  Holders. 


These  are  more  fully  described  by  figures  753  to  768.  Those  intended 
particularly  for  operations  on  the  eye  may  be  procured  in  a  limited  number 
of  patterns. 


Figure  1927.    Knapp's  Needle  Holder. 

Knapp's  Needle  Holder,  as  drawn  in  figure  1927,  is  a  delicate  clamp  of  the 
forceps  pattern,  one  blade  of  which  is  elongated  and  enlarged,  so  as  to  fur- 
nish a  suitable  handle,  the  whole  forming  an  instrument  about  6  inches  in 
length.  The  jaws  are  forced  apart  by  means  of  a  self-acting  spring. 


Figure  1928.    Stevens'  Needle  Holder. 

Stevens'   Needle  Holder  is  sketched  in  figure    1928.      This    instrument 
combines  the  essential  features  of  the  pattern  last  described,  together  with 


TRIDECTOMY  807 

the  automatic  lock  of  the  improved  Russian  needle  holder  shown  by  figure 
758.  While  of  the  same  length  as  the  pattern  designed  by  Knapp,  this  in- 
strument is  more  delicately  constructed,  and  is,  we  believe,  a  more  desirable 
pattern.  The  jaws  are  short  and  delicate  but  afford  ample  strength. 


Figure  1929.    Prout's  Needle  Holder. 

Prout's  Needle  Holder,  as  indicated  in  figure  1929,  was  for  many  years 
the  standard  instrument  employed  in  this  country  in  ophthalmic  suturing. 
It  differs  from  the  patterns  described  before  in  that  both,  handles  are  flat- 
tened and,  when  closed,  rest  closely  together  and  are  secured  by  a  sliding 
catch,  similar  to  that  employed  in  many  patterns  of  hemostatic  forceps. 
The  jaws  at  their  extremities  are  in  shape  like  flattened  discs,  one  of  which 
presents  a  smooth  surface,  the  other  one  having  creases  or  indentations  to 
prevent  the  needle  from  slipping. 

Syringes. 

Syringes  for  use  in  operations  on  the  eye  are  usually  of  the  plain  bulb 
pattern  without  valves.  They  hold  two  to  three  ounces,  and  may  be  ob- 
tained with  straight  and  spray  tips. 

Fountain  syringes  and  irrigators  are  also  employed  for  this  purpose,  the 
patterns  ordinarily  found  in  operating-rooms  answering  the  purpose. 


IRIDECTOMY. 

The  instruments  and  appliances  required  for  this  operation  are  as 
follows : 

General  list  of  eye  instruments  detailed  on  page    803. 

Speculum  for  separating  the  lids,  figures  1911  to  1915. 

Desmarre's  elevator,  figure  1917. 

Fixation  forceps  for  seizing,  grasping  and  holding  the  eye-ball. 

Knives  for  corneal  incisions. 

Iris  forceps  for  manipulation  of  iris. 

Iris  scissors  for  cutting  iris. 

Blunt  hook  for  lifting  or  retracting  iris. 

Spatula  for  replacing  or  removing  iris. 

Syringe  for  washing  eye,  figures  693  to  696. 

Fixation  Forceps. 

Fixation  forceps  are  required  to  seize  and  hold  or  steady  the  eye-ball  by 
grasping  the  conjunctiva  or  sub-conjunctival  tissues.  They  consist  of  a 
spring  forceps,  each  jaw  of  which  is  provided  with  teeth  similar  to,  but 
finer,  than  those  in  tissue  forceps.  The  jaws  are  usually  3  millimeters  in 
width,  each  containing  five  to  six  teeth.  In  most  patterns  the  row  formed  by 
the  closing  of  the  two  sets  of  teeth  is  concave  in  order  that  it  may  more  ac- 
curately conform  to  the  outer  shape  of  the  eye-ball.  The  teeth  should  pro- 
ject slightly  outward  from  the  forceps,  thus  securing  the  best  possible 
grasp.  They  may  be  either  straight  or  curved  and  with  or  without  catch. 


OPHTHALMIC  SURGERY. 


Those  with  catch  are  usually  preferred,  and  when  so  constructed,  while  the 
catch  should  be  firm,  it  must  be  of  a  self -locking  pattern  and  easily 
unclasped. 


Figure  1930.    Straight  Fixation  Forceps. 


Figure  1931.    Curved  Fixation  Forceps. 

The  Plain  Fixation  Forceps,  delineated  in  figures  1930  and  1931,  are 
without  catch,  differing  only  in  the  shape  of  the  shank,  one  being  curved 
at  an  angle  of  about  135°. 


Figure  1932.    Straight  Fixation  Forceps. 


The  Straight  Fixation  Forceps  with  catch,  outlined  in  figure  1932,  do 
not  differ  from  the  plain  forceps  shown  in  figure  1930  excepting  that  they 
are  provided  with  a  spring  catch.  Curved  forceps  with  a  similar  catch 
may  also  be  procured. 


Figure  1933.     Prince's  Fixation  Forceps. 

Prince's  Fixation  Forceps,  as  illustrated  in  figure  1933,  differ  materially 
in  the  shape  of  the  teeth  and  the  style  of  the  catch  from  those  above  de- 
scribed. The  teeth  in  this  instrument  consist  of  two  slightly  curved  hooks, 
one  upon  either  blade.  It  is  in  reality  a  double  tenaculum  forceps.  When 
the  jaws  are  closed,  the  hooks  are  forced  each  past  the  other,  so  that 
when  locked,  they  furnish  a  grasp  not  easily  broken.  The  lock  is  auto- 
matic and  so  adjusted  that  it  is  grasped  by  a  slight  pressure.  To  secure 
its  release  it  is  only  necessary  to  grasp  the  blades  firmly,  thus  avoiding  the 
necessity  of  forcing  back  the  head  of  the  spring  in  order  to  loosen  the  grip 
of  the  instrument. 

Ophthalmostats. 

These  consist  of  a  forked  bayonet,  each  prong  of  which  is  adjusted  for 
penetrating  the  conjunctiva  only  far  enough  to  obtain  a  good  control  of 
the  globe.  This  instrument  is  sometimes  used  on  restless  patients  instead 
of  fixation  forceps. 

Noyes'  Ophthalmostat,  as  shown  in  figure  1934,  is  a  bifurcated  bayo- 
net, each  prong  of  which  terminates  in  a  short-shouldered  needle.  Usually 
these  needles  are  from  10  to  12  millimeters  apart,  and  each  is  about  i 


IRIDECTOMY. 


millimeter  in  length.      It  terminates  in  a  square  shoulder  of  sufficient  ex- 
tent to  prevent  its  being  introduced  beyond  the  depth  mentioned. 


Figure  1934.     Noyes'  Ophthalmostat.  Figure  1935.    Three-Point  Ophthalmostat. 

The  Three-Point  Opthalmostat,  exhibited  in  figure  1935,  consists  of  a 
slender  shaft  terminating  in  a  three-pronged  spear  of  delicate  construction. 

Knives. 

Some  form  of  knife  is  required  for  making  the  corneal  incision.  They 
vary  in  design  from  the  short,  broad  lance  or  trowel-shaped  keratome,  or 
the  long,  slender  linear  knife  of  Von  Graefe,  to  the  spear-point  discission 
needles  more  commonly  used  in  some  forms  of  cataract.  Narrow  incis- 
ions are  usually  made  with  abroad  needle  having  a  double  edge,  or  a  short, 
narrow-bladed  knife,  that  may  be  either  straight,  curved  or  angular. 
Medium  or  ordinary  incisions  are  usually  performed  with  a  keratome, 
while  extra  wide  openings  are  made  with  a  slender  Yon  Graefe  knife. 

Keratomes,  frequently  described  as  lance  or  trowel-shaped  knives,  are 
more  commonly  used  for  this  operation.  They  may  be  procured  either 
straight  or  angular  bent,  the  former  being  used  where  an  incision  is  made 
lateral!}'  from  the  outer  margin ;  the  angular  form,  when  made  from  any 
other  direction.  They  are  either  plain  or  constructed  with  a  shoulder. 
This  latter  feature  ensures  the  operator  from  making  too  deep  an  incision. 
As  a  rule,  however,  this  pattern  is  employed  only  in  special  cases. 


Figure  1936.    Straight  Keratome. 


Figure  1937.    Angular  Keratome. 


Jaeger's  Keratomes,  as  set  forth  in  figures  1936  and  1937,  differ  only  in 
that  the  blade  of  one  is  bent  at  an  angle  with  the  handle  of  about  120°. 
They  are  usually  from  7  to  10  millimeters  from  point  of  base  to  the  cutting 
edge,  and  from  6  to  10  millimeters  in  width. 


Figure  1938.    Guarded  Keratome. 


Figure  1939.     Small  Iris  Knife. 


The  Guarded  Keratome,  best  understood  by  consulting  figure  1938,  may 
be  either  of  the  straight  or  angular  bent  pattern.  It  differs  from  the 
last-mentioned  varieties  only  in  being  provided  with  shoulders  that  effectu- 
ally prevent  its  introduction  beyond  the  depth  intended. 

The  Small  Iris  Knife,  as  is  apparent  in  figure  1939,  is  a  slender  blade, 
the  cutting  edge  of  which  may  vary  from  8  to  1 2  millimeters  in  length  and 
from  i  to  i  y<2.  millimeters  in  width.  It  is  of  the  well-known  center-point 
pattern. 


Figure  1940.     Hayes'  Knife  Needle. 


Figure  1941.     Iris  Knife  with  Stop. 


Hayes'  Knife  Needle,  a  likeness  of  which  may  be  seen  in  figure  1940, 
consists  of  a  slender,  sickle-shaped  knife  with  concave  cutting  edge,  ter- 


810 


OPHTHALMIC  SURGERY. 


initiating  in  a  sharp  point.     The  cutting  surface  is  usually  from  7  to  8  mil- 
limeters in  length  with  a  width  at  the  base  of  about  i^  millimeters. 

The  Iris  Knife,  with  stop,  shown  by  figure  1941,  is  a  slender  scalpel- 
shaped  blade  with  a  cutting  surface  about  7  millimeters  in  length  and  a 
width  of  blade  of  about  i  millimeter.  An  enlargement  or  shoiilder  on  the 
shaft  about  15  millimeters  from  the  point  of  the  blade  prevents  the  intro- 
duction of  the  instrument  beyond  that  depth. 

Iris  Forceps. 

These  are  a  slender  form  of  tissue  forceps.  They  are  usually  provided 
with  fine  mouse-teeth  by  which  the  iris  may  be  engaged,  retracted  or 
firmly  held  during  excision.  As  ordinarily  constructed,  they  are  provided 
with;teeth,  two  being  ttpon  one  blade,  between  which  the  third  tooth  on  the 
other  blade  closely  rests  when  the  forceps  are  closed.  They  may  be  pro- 
cured either  straight,  curved  or  angular.  They  are  particularly  adapted 
for  breaking  up  pupillary  adhesions.  They  are  employed  as  tissue  forceps 
in  many  operations  on  the  eye.  A  variety  manufactured  with  serrated 
jaws,  usually  called  eye  dressing  forceps,  will  be  found  useful  in  some 
operations. 


Figure  1944.    Angular  Iris  Forceps. 

The  Iris  Forceps,  displayed  in  figures  1942,  1943  and  1944,  represent  the 
regular  patterns.  Of  these,  the  curved  one  is  preferred  by  nearly  all  oper- 
ators, the  straight  one  being  recommended  by  some  authors  in  cases  where 
complete  removal  of  the  iris  is  necessary. 


Figure  1945.    Liebrich's  Rotating  Iris  Forceps. 

Liebrich's  Rotating  Iris  Forceps,  as  defined  by  figure  1945,  are  particu- 
larly useful  for  operating  through  a  narrow  incision,  as  the  jaws  may  be 
spread  without  widening  that  portion  of  the  instrument  which  rests  directly 
within  the  wound  margins.  It  is  a  desirable  pattern  for  tearing  an  iris 
from  any  attachments,  and  also  for  use  in  operating  for  membranous 
cataract. 

Scissors. 

Scissors  are  necessary  for  removing  sections  of  the  iris.  For  this  pur- 
pose  they  should  be  delicate,  sharp-pointed  and  of  the  best  possible  con- 


IRIDECTOMY. 


811 


struction.     At  the  points  they  must  cut  smoothly  and  evenly  and  not  pass 
by  or  override  each  other.     They  may  be  straight,  curved  or  angular  bent. 


Figure  1947. 


The  Iris  Scissors,  shown  by  figures  1946  and  1947,  differ  from  each 
other  only  in  shape,  one  being  straight  and  the  other  curved  on  the  flat ;  both 
are  of  delicate  construction  and  have  sharp  points. 


Figure  1948.    Wecker's  Iris  Scissors. 

Wecker's  Iris  Scissors,  as  illustrated  in  figure  1948,  have  slender  spring 
forceps-shaped  blades,  resting  upon  and  hinged  at  their  under  or  posterior 
margins.  Each  terminates  in  a  short  scissors  blade,  having  a  cutting 
edge  about  10  millimeters  in  length  and  bent  at  an  angle  of  about  45° 
with  the  long  axis  of  the  instrument.  Two  oval  perpendicular  projections 
near  the  center  of  each  blade  furnish  the  power  by  which  the  blades  are 
closed.  By  their  peculiar  construction,  when  the  hinge  is  in  place,  they 
are  self-opening,  thus  requiring  no  spring.  They  are  not  only  useful  in 
iridectomy,  but  are  especially  recommended  in  iridotomy. 


Figure  1949.    Noyes'  Iris  Scissors. 


Noyes'  Iris  Scissors,  as  pictured  in  figure  1949,  are  constructed  with  ex- 
ceedingly delicate  blades  and  shanks.  The  fixed  or  upper  blade  termi- 
nates in  a  long  rigid  handle  by  which  the  instrument  is  manipulated.  The 
under  or  moving  blade  terminates  in  a  broad  flattened  base  that  admits  of 
thumb  manipulation,  by  which  the  scissors  are  operated. 

Iris  Hooks. 

Either  blunt  or  sharp  hooks  are  frequently  used  for  manipulating  the 
iris  in  place  of  forceps,  particularly  when  operating  through  a  narrow  in- 


812 


OPHTHALMIC  SURGERY. 


cision  or  where  a  small  pupil  is  desired.  They  should  be  manufactured 
with  malleable  shanks,  that  they  may  be  adjusted  to  different  conditions. 
Special  forms  are  constructed  for  separating  pupillary  adhesions. 


Figure  1950.    Tyrrell  s  Blunt  Iris  Hook.  Figure  1951.    Tyrrell's  Sharp  Iris  Hook 

Tyrrell's  Iris  Hooks,  as  portrayed  in  figures  1950  and  1951,  differ  only 
in  the  construction  of  the  tips,  one  being  blunt  and  the  other  sharp- 
pointed.  The  lateral  diameter  of  each  hook  is  usually  from  i  to  i  y2  milli- 
meters. 


Figure  1952.     Weber's  Iris  Hook.  Figure  1953.     Von  Graefe  s  Iris  Hook. 

Weber's  Iris  Hooks,  as  shown  in  figure  1952,  are  constructed  in  pairs 
for  the  right  and  left  eye,  the  shaft  being  bent  at  an  angle  of  about  45° 

Von  Graefe's  Iris  Hook,  which  may  be  seen  in  figure  1953,  is  a  larger 
and  heavier  pattern  than  those  before  described,  the  wire  not  only  being 
of  a  larger  size,  but  the  hook  having  an  external  diameter  01  2*^  to  3  milli- 
meters. The  shaft  is  bent  slightly  backward,  so  that  the  point  of  the  hook 
lies  in  the  long  axis  of  the  instrument.  An  enlargement  or  ring  constructed 
in  the  shaft  about  1 2  millimeters  from  its  extremity,  serves  as  a  stop,  by 
means  of  which  the  instrument  need  not  be  introduced  beyond  a  proper 
depth. 

Spatulas. 

These  consist  of  flat  slender  blades  with  dull  round  tips.  They  are 
employed  to  separate  the  lips  of  corneal  wounds,  to  make  pressure,  to  assist 
in  the  movement  of  semi-solids,  and  to  arrest  hemorrhage.  They  will  be 
found  useful  as  foreign  body  instruments,  not  only  for  everting  the  lids,  but 
as  extractors.  They  are  manufactured  from  shell,  metal  and  hard  rubber, 
the  two  former  being  preferred.  Usually  they  are  thin  enough  to  furnish 
elastic  resistance  when  pressed  upon. 


TftAUX,  aftttNE  *  CO. 


Figure  1954.    Althoff's  Steel  Spatula. 


Figure  1955.    Plain  Spatula. 


Althoff's  Steel  Spatula,  as  exhibited  in  figure  1954,  is  usually  from  2^ 
to  3  millimeters  in  breadth  by  25  in  length. 

The  Plain  Spatula,  illustrated  in  figure  1955,  may  be  made  from  rubber, 
tortoise  shell  or  German  silver.  The  blade  is  usually  \y2  or  2  millimeters 
in  breadth  by  about  30  in  length. 


CATARACT. 

As  cataract  operations  sometimes  involve  an  iridectomy,  the  list  of  in- 
struments advised  will  include  those  employed  in  that  procedure,  with  such 
special  ones  as  are  generally  considered  necessary.  A  complete  list  for  flap 
operations  and  linear  extraction  is  as  follows: 

General  list  for  operations  on  the  eye,  page  803. 


CATARACT.  813 

Speculum  for  separating  the  lids,  figures  ign  to  1916. 
2  Desmarre's  retractors  for  lifting  lids,  figure  1917. 

Fixation  forceps  for  grasping  and  holding  eyeball,  figures  1930  to  1933 
Iris  scissors,  sharp-pointed,  for  delicate  incisions,  figures  1946  and  1947. 
Iris  forceps  for  delicate  dissections,  figures  1942  to  1944. 
Spatula  for  manipulation  of  inner  structures,  figures  1954  and  1955. 
Irrigator,  figures  639  to  696. 
Knives  for  corneal  incisions. 
Scissors,  probe  pointed,  for  special  cases. 
Cystotome. 
Capsule  forceps. 
Scoops. 
If  for  Needle  Operation: 

Speculum  for  separating  the  lids,  figures  1911  to  1916. 

Fixation  forceps    for  grasping  and  holding  eye  ball,   figures  1930  to 

'933- 

Cataract  needles  or  knife  needles. 
If  by  Suction: 

Some  form  of  soft  cataract  aspirator. 

Cataract  Knives. 

Knives  for  making  the  incision  through  the  cornea  in  cataract  opera- 
tions vary  according  to  the  ideas  of  the  operator  and  the  method  selected. 
For  linear  extraction  many  employ  a  keratome,  such  as  is  used  in  iridec- 
tomy ;  others  prefer  the  small  iris  knives,  plain  or  with  stop,  as  shown  in 
figures  1974  to  1976.  The  majority  of  operators,  however,  make  use  of 
knives  with  long,  slender  blades. 


Figure  1956.    Von  Graefe's  Cataract  Knife.  Figure  1957      Knapp's  Hollow  Ground 

Cataract  Knife. 

Von  Graefe's  Cataract  Knife,  as  it  appears  in  figure  1956,  is  usually 
constructed  with  a  cutting  edge,  varying  from  30  to  35  millimeters  in 
length,  two-thirds  of  the  length  of  the  blade  being  straight,  and  the  outer 
third  beveled  from  back  and  front  and  sharpened  to  a  fine  point.  These 
knives  may  usually  be  obtained  in  three  widths,  i^,  2  and  2^  millimeters. 
Knives  wider  than  the  latter  are  seldom  employed  in  this  operation. 

Knapp's  Hollow  Ground  Cataract  Knife,  as  represented  in  figure  1957, 
differs  from  the  pattern  of  Von  Graefe  mainly  in  that  the  face  is  hollow 
ground,  similar  to  that  of  many  patterns  of  razors. 


Figure  1958.     Beer's  Cataract  Knife.  Figure  1959.     Schweigger's  Cataract  Knife. 

Beer's  Cataract  Knife,  as  illustrated  in  figure  1958,  has  a  triangular 
blade  with  a  cutting  surface  varying  from  25  to  35  millimeters  in  length  and 
from  8  to  10  millimeters  in  width  at  the  base.  The  better  forms  are 
ground  until  extremely  thin  and  with  very  sharp  points. 

Schweigger's  Cataract  Knife,  as  shown  in  figure  1959,  differs  from  the 
pattern  of  Von  Graefe  only  in  being  broader  and  heavier. 


814 


OPHTHALMIC  SURGERY. 


Cataract  Scissors. 


Scissors  with  probe  points  are  frequently  required  for  enlarging  incis- 
ions, etc. 


Figure  1960.    Probe-Pointed  Iris 
Scissors. 

The  Probe-Pointed  Iris  Scissors,  seen  by  referring  to  figure  1960,  differ 
from  those  shown  by  figure  1947  only  in  being  constructed  with  one  or  both 
points  of  bulbous  or  probe  form. 

Cystotomes. 

A  cystotome  consists  of  a  slender  shank  terminating  in  a  short  sharp 
tooth  or  sickle-shaped  point  projecting  at  or  nearly  a  right  angle  with  the 
shaft.  It  is  employed  for  opening  or  dividing  the  capsule  in  linear  extrac- 
tion. It  should  be  so  constructed  that  it  will  not  tear,  but  cut  the  tissues. 
It  may  be  straight  or  curved,  right  or  left. 


Figure  1961.    Von  Graefe's  Straight  Cystotome. 


Figure  1962.    Knapp's  Cystotome. 


Von  Graefe's  Straight  Cystotome,  as  drawn  in  figure  1961,  has  a  slender 
yet  strong,  round  shaft  terminating  in  a  sickle-shaped  point,  projecting  at  a 
right  angle  with  the  shank.  The  point  should  not  exceed  i  millimeter  in 
length,  should  be  triangular  in  form,  with  a  sharp  anterior  edge,  that  the 
instrument  may  cut  with  a  drawing  or  pulling  motion.  This  pattern  is 
usually  preferred  for  primary  incisions. 

Knapp's  Cystotome,  as  outlined  by  figure  1962,  varies  from  the  straight 
pattern  of  Von  Graefe  in  two  particulars :  The  sickle-shaped  point,  instead 
of  being  at  right  angles,  projects  slightly  outward,  while  the  inner  face  of 
the  shaft  next  to  the  point  is  flattened  and  sharpened  to  a  cutting  edge  for 
about  4  or  5  millimeters.  This  edge  extends  from  the  shaft  along  the  face 
of  the  triangular  point  to  its  apex.  This  pattern  is  recommended  by  some 
authors  for  operations  following  iridectomy. 

Capsule  Forceps. 

Capsule  forceps  consist  of  slender  forceps  with  the  extremities  of  the 
blades  angular  bent.  The  outer  margins  of  these  jaws  are  usually  provided 
with  fine  sharp  teeth.  They  are  employed  to  engage  and  remove  the 
capsule. 


Figure  1963.    De  Schweinitz'  Capsule  Forceps. 

De  Schweinitz'  Capsule  Forceps,  as  portrayed  in  figure  1963,  consist  of 
delicate  spring  forceps  with  crossing  blades,  the  shanks  of  which  are  curved 


CATARACT. 


815 


downward  at  an  angle  of  about  120°.  The  outer  borders  of  the  delicate 
jaws  are  provided  with  a  series  of  sharp  projecting  teeth  of  such  shape  as  to 
form  a  firm  contact  with  the  capsule.  The  forceps  are  closed  by  lateral 
compression  of  the  handles. 


Figure  1964.     Foerster's  Capsule  Forceps. 

Foerster's  Capsule  Forceps,  as  set  forth  in  figure  1964,  differ  from  the 
curved  iris  forceps  in  that  the  teeth  are  located  on  the  outer  terminal  mar- 
gins of  the  forceps  jaws.  The  teeth  are  of  fine  construction,  project  slightly 
outward,  and  are  usually  about  seven  in  number 

Scoops. 

Scoops  are  a  form  of  curette,  in  spoon  or  loop  form,  employed  in  various 
operations  on  the  eyes.  They  may  be  used  for  scooping  out  fluid  or  semi- 
fluid substances,  for  pressure  or  counter-pressure,  for  expressing  matter 
through  a  wound  opening  (for  this,  two  are  occasionally  required)  for  remov- 
ing foreign  growths,  recovering  a  lens  that  may  have  fallen  into  the 
vitreous,  retracting  rigid  sphincters,  etc. 


Figure  1965.    Daviel's  Scoop. 


Figure  1966.    Wecker's  Sharp  Edge  Scoop. 


Daviel's  Scoop,  as  disclosed  by  figure  1965,  consists  of  a  slender  concave 
spoon  about  3  millimeters  in  width,  with  its  depression  about  12  millimeters 
in  extent.  Its  edges  are  dull  or  well-rounded,  the  whole  instrument  being 
smooth  and  without  sharp  angles.  It  is  usually  manufactured  from  German 
silver. 

Wecker's  Sharp-Edge  Scoop,  as  pictured  in  figure  1966,  differs  from  the 
pattern  of  Daviel,  in  being  constructed  from  steel,  provided  with  sharp  cut- 
ting edges,  and  a  trifle  more  slender  in  form. 


Figure  1967.    Critchet's  Concave  Scoop.  Figure  1968.    Knapp's  Large  Scoop. 

Critchet's  Concave  Scoop,  as  shown  in  figure  1967,  is  a  small,  thin,  oval 
disc,  the  outer  margin  of  which  is  provided  with  a  projecting  lip  or  rim  that 
presents  a  semi-cutting  edge.  The  width  is  usually  from  4  to  5  millimeters. 

Knapp's  Large  Scoop,  as  portrayed  in  figure  1968,  is  a  deep  spoon  with 
a  flexible  shank.  It  is  particularly  adapted  to  cases  where  large  quantities 
of  matter  have  to  be  scooped  out.  It  is  usually  manufactured  from  silver. 


Figure  1969.    Waldeau's  Scoop.  Figure  1970.    Feijestrated  Scoop. 

Waldeau's  Scoop,  as  illustrated  by  figure  1969,  is  small,  oval,  and  manu- 
factured from  silver  with  a  flexible  shank.  Its  narrow  diameter  is  about  4 
millimeters. 

The  Fenestrated  Scoop,  depicted  in  figure  1970,  is  a  plain  wire  loop  with- 
out sharp  edges  or  margins.  Ordinarily  the  loops  are  oval,  the  short 
diameter  being  about  4  millimeters. 


816 


OPHTHALMIC  SURGERY. 


Cataract  Needles. 


Cataract  or  knife  needles  consist  of  lance-shaped  needles  or  minute  slen- 
der knives  used  for  lacerating  the  capsule.  Some  oculists  employ  two  in 
every  operation.  Several  patterns  are  constructed  with  stops  as  a  guard 
against  the  accidental  introduction  of  the  instrument  beyond  a  proper  depth. 
They  are  occasionally  used  in  secondary  cataract,  and  the  broader  designs 
are  sometimes  employed  in  evacuating  a  fluid  cataract. 


Figure  1971.    Small  Cataract  Needle. 


Figure  1972.    Large  Cataract  Needle. 


The  Small  Cataract  Needle,  defined  by  figure  1971,  is  in  lance  form, 
about  ^  to  24  of  a  millimeter  in  width  at  its  broadest  part.  A  similar  needle 
i  to  i^  millimeters  in  width  may  be  procured  from  most  dealers. 

The  Large  Cataract  Needle,  shown  in  figure  1972,  is  manufactured  with 
a  long,  slender,  double-edged  blade  about  i  ^  millimeters  wide. 


Figure  1973.    Plain  Knife  Needle. 


Figure  1974.     Knapp's  Stop  Iris  Needle. 


The  Plain  Knife  Needle,  illustrated  by  figure  1973,  is  a  slender  sharp- 
pointed  knife  about  i  millimeter  in  width  at  its  base  and  with  a  cutting  edge 
about  5  millimeters  in  extent. 

Knapp's  Stop  Iris  Needle,  as  portrayed  by  figure  1974,  is  a  small  sickle- 
shaped  knife  with  a  concave  edge.  Its  cutting  surface  is  about  3  millime- 
ters in  length  and  its  breadth  at  the  base  about  i  millimeter. 


Figure  1975.    Plain  Iris  Needle. 


Figure  1976.    Bowman's  Stop  Needle. 


The  Plain  Iris  Needle  with  Stop,  shown  in  figure  1975,  is  a  round,  sharp- 
pointed  needle,  provided  with  an  enlargement  or  stop  about  15  millimeters 
from  its  distal  end. 

Bowman's  Stop  Needle  differs  from  the  plain  pattern  in  that  it  is  con- 
structed with  a  small  spear-shaped  point,  as  illustrated  in  figure  1976.  It 
is  about  i  millimeter  broad  in  the  widest  part  of  its  blade. 

Cataract  Exhauster. 

These  are  a  form  of  evacuator  adapted  for  soft  cataracts.  This  oper- 
ation differs  from  the  extraction  method  in  that  the  loosened  or  fluid  mat- 
ter is  removed  through  a  hollow  needle  by  vacuum  pressure. 


Figure  1977.    Teale's  Plain  Suction  Tube 
for  Soft  Cataract. 


Teale's  Plain  Suction  Tube  for  Soft  Cataract,  as  may  be  seen  in  figure 
1977,  comprises  a  glass  pipe  terminating  in  a  long,  slender  curved  point, 
provided  with  a  fine  opening  at  its  tip.  A  rubber  hose,  a  foot  or  more  in 


STAPHYLOMA. 


$17 


length,  connects  the  glass  pipe  with  a  suitable  mouth-piece,  by  means  of 
which  the  operator  is  enabled  to  suck  or  draw  the  fluid  contents  of  the 
cataract  into  the  pipe. 


Figure  1978.    Bowman's  Soft  Cataract  Instrument. 


Bowman's  Soft  Cataract  Instrument,  easily  understood  by  referring  to 
figure  1978,  consists  of  a  metallic  cylinder  about  4  inches  in  length,  to  which 
is  attached  a  blunt-pointed  hypodermic  needle.  A  side  opening  in  the 
cylinder  permits  the  attachment  of  a  rubber  hose,  the  latter  terminating  in 
a  tip  to  which  suction  may  be  applied,  either  by  the  mouth  or  by  a  soft  rub- 
ber syringe  bulb  connected  with  the  exhaust  valve  next  to  the  instrument. 
When  in  use,  the  cylinder  receives  the  fluid  extracted  from  the  eye. 


Figure  1979.    Teale's  Soft  Cataract  Instrument. 

Teale's  Soft  Cataract  Instrument,  as  portrayed  in  figure  1979,  consists 
of  a  hollow  cylindrical  chamber,  one  end  of  which  is  attached  to  the  evacu- 
ating tube,  while  to  the  other  is  connected  a  soft  rubber  hose  and  mouth- 
piece by  which  suction  is  produced.  The  tubes  or  needles  are  slightly 
curved  at  their  distal  ends,  and  the  openings  are  large  and  bell-shaped,  some- 
what in  curette  form. 


STAPHYLOMA. 


Staphyloma,  when  relieved  by  surgical  procedure,  will  require  nearly,  if 
not  all,  of  the  following : 

General  list  of  eye  instruments  on  page  803. 

Speculum  for  separating  lids,  figures  1911  to  1916. 

Fixation  forceps  to  hold  and  steady  eyeball,  figures  1930  to  1933. 

Tissue  forceps  for  holding  mass  to  be  removed,  figures  1942  to  1944. 

Scalpel. 

Scissors,  sharp-pointed,  for  enlarging  opening  or  removal  of  section. 

Needles,  figures  1923  to  1926. 

Needle  holder,  figures  1927  to  1929. 

Sutures,  silk  or  catgut,  figures  708  to  728. 

52 


818 


OPHTHALMIC  SURGERY. 


Scalpels. 

These  are  employed  in  various  operations  on  or  about  the  eye  They 
may  be  procured  of  two  patterns,  the  regular  form  and  the  center  point. 
The  sizes  ordinarily  in  use  are  shown  by  the  following  illustrations; 


Small. 


Medium, 
Figure  1980.    Eye  Scalpels,  Shown  Full  Size. 


Large. 


The  Eye  Scalpels,  sketched  in  figure  1980,  show  the  sizes  most  commonly 
in  use.  Like  other  patterns  of  cutting  instruments,  they  can  be  procured 
of  any  desired  size. 

Staphyloma  Scissors. 

Scissors  suitable  for  this  operation,  either  curved  on  the  flat  or  straight, 
may  be  obtained  of  various  lengths  and  weights,  those  here  shown  being 
adapted  for  many  other  operations. 


Figure  1981.    Heavy,  Straight  Staphyloma 
Scissors. 


Figure  1982.    Heavy,  Curved  on  the  Flat 
Staphyloma  Scissors. 


The  Heavy  Staphyloma  Scissors,  indicated  in  figures  1981  and  1982,  differ 
from  the  ordinary  iris  patterns  only  in  being  heavier.  These  sizes  and 
strengths  are  often  used  for  iridectomy  instead  of  the  lighter  patterns  shown 
in  figures  1946  and  1947. 


TATTOOING  THE  CORNEA. 

This  operation  for  the  relief  of  opacity,  requires : 

Speculum  for  separating  lids,  figures  1911  to  1916. 

Fixation  forceps  for  controlling  movements  of  eyeball,  figures  1930  to 

1933- 

Tattooing  needles  for  pricking  in  of  India  ink. 
India  ink. 


PARACENTES1S EVISCERATION.  819 

Tattooing-  Needles. 

These  are  usually  constructed  by  securing  a  number  of  sewing  needles 
in  such  a  manner  that  the  points  will  all  rest  in  the  same  plane.  The  ink 
employed  must  be  India  ink  of  the  finest  quality  which  may  be  purchased 
from  dealers  in  artists'  supplies. 


Figure  1983.    Agnew's  Tattooing  Needle.  Figure  19*4.    Plain  Tattooing  Needle. 

Agnev/'s  Tattooing  Needle,  as  illustrated  in  figure  1983,  consists  of  a 
blade  to  which  are  attached  five  or  six  fine  cambric  needles  resting  side  by 
side.  The  width  of  the  entire  instrument  should  not  exceed  2  or  2^ 
millimeters. 

The  Plain  Tattooing  Needle,  shown  in  figure  1984,  consists  of  a  number 
of  ordinary  sewing  needles,  clamped  in  a  small  holder. 


PARACENTESIS. 

Paracentesis  of  the  cornea  may  be  made  by  direct  puncture  with  the 
needle,  trocar  or  knife,  or  with  the  thermo-cautery,  as  described  by  figures 
397  to  400. 

Direct  puncture  requires : 

Speculum  for  separating  eyelids,  figures  1911  to  1916. 

Fixation  forceps  for  controlling  the  action  of  eyeball,  figur 


es  1930  to 


Needle,  trocar  or  knife,  for  perforation  of  cyst. 

Paracentesis  Needles. 


These  differ  from  iris  needles,  principally  in  being  broader  and  heavier. 
Some  patterns  are  provided  with  a  stop,  in  order  to  prevent  too  deep  intro- 

duction. 


Figure  1985.    Desmarre's  Paracentesis  Needle.  Figure  1986.    Paracentesis  Knife. 

Desmarre's  Paracentesis  Needle,  as  portrayed  in  figure  1985,  is  a  lance- 
pointed  needle  from  2  to  2^4  millimeters  broad  at  the  base  and  from  3  to  4 
millimeters  in  length.  The  cutting  or  piercing  edges  terminate  in  a 
shoulder  so  constructed  as  to  avoid  injury  that  might  result  from  the  intro- 
duction of  the  instrument  to  too  great  a  depth. 

The  Plain  Paracentesis  Knife,  exhibited  in  figure  1986,  does  not  differ 
from  some  of  the  ordinary  forms  of  iris  needles. 


EVISCERATION  OR  EXENTERATION. 

From  a  prosthetic  standpoint  this  is  preferable  to  complete  removal  of 
the  eyeball,  as  it  furnishes  a  good  stump  by  means  of  which  more  or  less 
movement  may  be  imparted  to  an  artificial  eye.  The  instruments  necessary 
are: 

General  list  of  eye  instruments,  described  on  page  803. 


820  OPHTHALMIC  SURGERY. 

Speculum  for  separating  lids,  figures  1911  to  1916. 

Fixation  forceps  for  controlling  the  movements  of  eyeball,  figures  1930 
to  1933. 

Knife  for  incision,  figure  1980. 

Scissors  for  enlarging  section  and  removal  of  portion  of  cornea,  figures 
1981  and  1982. 

Scoop  or  spoon  for  removal  of  contents  of  eyeball,  figures  1965  to  1969. 

Needles  for  suturing,  figures  1923  to  1926. 

Needle  holder,  figures  1927  to  192 9. 

Silk  or  catgut,  figures  708  to  728. 


ENUCLEATION. 

Enucleation  of  the  eyeball  requires : 

General  list  of  eye  instruments,  detailed  on  page  803. 

Speculum  for  separating  lids,  figures  1911  to  1916. 

Fixation  forceps  for  controlling'  movements  of  eyeball,  figures  1930  to 
1933. 

Tissue  forceps  for  retracting  the  eyeball  and  drawing  it  from  the  orbit, 
figures  1942  to  1945. 

Strabismus  hook  for  separating  and  raising  tendons,  figure  1990. 

Enucleating  scissors. 


Figure  1987.    Enucleating  Scissors. 


The  Enucleating  Scissors,  sketched  in  figure  1987,  represents  the  pattern 
usually  employed.  This  operation  may  be  performed  with  ordinary  curved- 
on-the-flat  scissors,  such  as  are  shown  by  figure  635.  Most  operators,  how- 
ever, prefer  an  instrument  a  trifle  more  slender  and  with  a  longer  cutting 
surface.  The  scissors  above  illustrated  are  from  5  to  5^  inches  in  length 
with  a  cutting  surface  of  i  %  inches. 


PTERYGIUM. 

The  excision  of  pterygium  requires: 

General  list  of  eye  instruments,  as  described  on  page  803. 

Fine  tissue  forceps  for  grasping  the  growth,  figures  1942  to  1944. 

Knife  for  separating  attachments,  figure  1980. 

Scissors  with  fine  points  for  dissecting  base  or  separating  attachments. 

Hook  for  tearing  the  pterygium  from  the  conjunctiva. 

Needles  for  suture,  figures  1923  to  1926. 

Needle  holder,  figures  1927  to  1929. 

Silk  or  catgut,  figures  708  to  728. 

Other  methods,  as  a  rule,  require  nearly  the  same  list  of  instruments. 


STRABISMUS. 


821 


Pterygium  Scissors. 

These  are  of  somewhat  slender  construction  with  sharp  points.  They 
are  employed  for  separating  the  base  of  the  attachment  and  sometimes  for 
complete  excision  of  the  growth. 


Figure  1988.    Plain  Pterygium  Scissors. 

The  Plain  Pterygium  Scissors,  exhibited  in  figure  1988,  do  not  differ 
materially  from  those  employed  in  operations  on  the  iris,  excepting  that,  as 
a  rule,  they  are  somewhat  heavier  and  are  usually  straight. 


Figure  1989.    Prince's  Pterygium  Divulser. 

Prince's  Pterygium  Divulser,  as  depicted  in  figure  1989,  consists  of  a  firm 
shank  terminating  in  a  short  cutting  blade  bent  at  a  right  angle  with  the 
shaft  It  is  employed  to  separate  the  corneal  portion  of  the  pterygium,  after 
which  the  denuded  surface  is  freed  from  any  adhering  opaque  tissues  by 
means  of  Desmarre's  scarificator  or  some  similar  instrument. 


STRABISMUS  BY  TENOTOMY. 

This  operation  requires : 

General  list  of  eye  instruments,  described  on  page  803. 

Speculum  or  lid  elevator  for  separating  the  lids,  figures  1911  to  1920. 

Fixation  forceps  for  controlling  movement  of  eyeball,  figures  1930  to 

1933 

Fine  tissue  forceps  for  grasping  parts  to  be  severed,  figures  1942  to  1944. 
2  Strabismus  hooks  for  raising  and  holding  muscles. 
Slender  scissors,  probe-or  round-pointed,  for  severing  muscles. 
Divulser  for  separating  tendon  from  surrounding  tissues. 

Strabismus  Hooks. 

These  consist  of  slender  hooks  curved  to  pass  under  and  raise  the  mus- 
cles to  be  severed.     The  curved  portion  may  vary  from  5  to  10  millimeters 


Figure  1990.    Von  Graefe's  Strabismus  Hook. 


Figure  1991.    Stevens'  Strabismus  Hook. 


in  length,  terminating  in  a  rounded  or  bulbous  point.  They  may  be  pro- 
vided with  an  eye  in  the  point,  and  thus  serve  as  ligature  carriers.  They 
are  employed  to  raise  and  hold  muscles  for  excision. 


822 


OPHTHALMIC  SURGERY. 


Von  Graefe's  Strabismus  Hook  exhibits  the  most  common  form  of  stra- 
bismus hook  in  use.  It  consists  of  a  strong  wire  shank,  curved  near  its  ex- 
tremity, at  about  a  right  angle,  and  terminating  in  a  bulbous  point,  as  shown 
in  figure  1990.  Usually  it  may  be  obtained  in  three  sizes,  the  curved  prong 
in  each  being  8,  9  and  10  millimeters  in  extent,  respectively. 


McDonald's  Strabismus 
Hook. 


Figure  1993.    Agnew's  Strabismus 
Hook. 


McDonald's  Strabismus  Hook,  according  to  figure  1992,  represents  a 
pattern  terminating  in  a  barb  something  after  the  design  of,  but  not  so  sharp 
or  long  as,  a  fishhook.  Some  operators  prefer  this  pattern,  because  there 
is  less  danger  of  the  muscle  slipping  over  and  off  the  instrument. 

Agnew's  Strabismus  Hook,  as  depicted  in  figure  1993,  differs  from  the 
pattern  of  Von  Graefe,  in  that  the  tip  is  broad  and  somewhat  flattened 
instead  of  being  bulbous,  and  that  it  has  an  eye  near  its  point. 

Stevens'  Strabismus  Hook,  as  traced  in  figure  1991,  differs  from  the 
patterns  previously  described,  in  being  much  smaller  and  more  delicate. 
In  general  form  it  is  nearly  like  that  of  Von  Graefe,  but  the  curved  portion 
is  not  more  than  5  millimeters  in  length.  The  delicacy  of  the  hook  enables 
the  operator  to  insert  it  beneath  the  tendon  at  the  extremities  of  a  pre- 
viously made  section  without  including  or  disturbing  surrounding  tissues. 

Strabismus  Scissors. 

Strabismus  scissors  should  be  firm  in  construction,  strong  enough  to 
sever  dense  muscular  fiber,  curved  on  the  flat  and  should  have  round  or 
probe-pointed  tips. 


Figure  1994.     Plain  Strabismus  Scissors. 


The  Plain  Strabismus  Scissors,  delineated  in  figure    1994,    are    usually 
about  4*/2  inches  in  length,  heavier  than  those  used  for  operations  on  the 


Figure  1995.     Straight  Strabismus  Scissors. 


ins  and  curved  upon  the  flat.  The  blades  are  carefully  rounded,  presenting 
no  angles.  The  tips  are  narrow  and  blunt,  and  the  scissors  so  constructed 
that  they  will  cut  well  at  the  extreme  ends. 


STRABISMUS. 


823 


The  Straight  Strabismus  Scissors,  illustrated  by  figure  1995,  differ  from 
the  curved  scissors  last  described,  only  in  being  straight. 


Figure  1996.    Stevens'  Strabismus  Scissors. 


Stevens'  Strabismus  Scissors,  as  displayed  in  figure  1996,  do  not  differ 
materially  in  width  and  length  from  those  last  described.  The  principal 
difference  consists  in  the  narrowing  of  the  blades  near  the  points,  thus  fur- 
nishing an  instrument  slender  at  the  blade  tips  without  sacrifice  of  strength. 
The  points  are  so  delicate  and  slender  that  they  may  be  used  to  operate 
beneath  the  conjunctiva  through  a  very  small  opening. 

Traction    Hooks. 

These  are  delicate  sharp-pointed  hooks  for  insertion  in  the  cut  margin 
of  the  severed  tendon,  to  assist  in  retraction  and  resection. 


Figure  1997.    Stevens'  Traction  Hook. 


Figure  1998.    Stevens'  Divulser. 


Stevens'  Traction  Hook,  as  it  appears  in  figure  1997,  is  a  delicate  shank 
with  an  angular  barb,  the  latter  having  a  backward  or  proximal  angle  of 
45°.  As  the  shaft  is  very  slender,  the  barb  is  made  fine  and  sharp,  that  it 
may  be  easily  inserted  into  the  cut  border  of  the  muscle. 

Divulsers. 

Divulsers  are  employed  to  separate  the  tendon  from  surrounding  tissues. 
They  consist  of  some  form  of  separator  or  dissector. 

Stevens'  Tendon  Divulser,  as  detailed  in  figure  1998,  consists  of  a  small 
lance-shaped  blade  about  i  millimeter  broad,  the  tip  of  which  terminates  in 
an  olive-  or  button-point,  thus  serving  as  a  leader  in  separating  tissues. 


STRABISMUS  BY  ADVANCEMENT. 

Strabismus  by  advancement  of  a  rectus  muscle  usually  requires: 

General  list  of  eye  instruments,  on  page  803. 

Speculum  or  lid  retractor  for  separating  the  lids,  figures  1911  to  1916. 

Scissors  for  detaching  the  muscle,  figures  1994  to  1996. 

Fixation  forceps  for  controlling  movement  of  eyeball,  figures  1930  to  1933. 

2  Strabismus  hooks  for  raising    and  holding  muscles,  figures  1990  to 

*993- 

Advancement  forceps  for  clasping  and  placing  the  severed  muscle. 
Needles  for  suturing,  figures  1923  to  1926. 
Needle  holder,  figures  1927  to  1929. 
Silk  or  catgut,  figures  708  to  728. 


824  OPHTHALMIC  SURGERY. 

Advancement   Forceps. 

These  consist  of  a  muscle  clamp  by  which'  the  end  of  the  severed  tendon 
may  be  secured  and  held  in  place  until  sutured. 


Figure  1999.    Prince's  Advancement  Forceps. 


Prince's  Advancement  Forceps,  as  set  forth  in  figure  1999,  in  general 
form  resemble  angular  iris  forceps.  The  bent  portion  is  about  8  to  10  mil- 
limeters in  length,  on  the  outer  surface  of  which  are  four  sets  of  interlocking 
teeth,  each  set  comprising  the  combination  known  as  mouse-teeth ;  that  is, 
two  upon  one  side  and  one  upon  the  other,  the  three  interlocking  to  form  a 
"bite."  The  instrument  is  supplied  with  a  spring  catch. 


Figure  2000.    Wecker's  Strabismus  Clamp. 

Wecker's  Strabismus  Clamp  for  advancing  the  muscle,  as  shown  in  fig- 
ure 2000,  is  provided  with  one  fixed  and  one  sliding  jaw,  the  latter  operated 
by  thumb  movement.  The  jaws  are  bent  at  an  angle  of  about  110°  with 
the  shank.  The  moving  blade  is  supplied  on  its  outer  surface  with  two 
teeth  that  fit  into  recesses  provided  in  the  outer  blade.  With  this  instru- 
ment a  firm  grasp  may  be  secured  upon  the  severed  muscle  until  it  is 
sutured. 


ENTROPION. 

The  operation  for  this  condition  requires  the  following: 
General  list  of  eye  instruments  described  on  page  803. 
Lid  forceps  for  clamping  and  holding  lid. 
Lid  elevator  for  shielding  or  protecting  the  eyeball. 
Scalpel  or  other  knife  for  incision,  figure  1980. 
Needles  for  sutures,  figures  1923  to  1926. 
Needle  holder,  figures  1927  to  1929. 
Silk  or  catgut,  figures  708  to  728. 

Lid  Forceps. 

Lid  forceps  consist  of  clamps  controlled  either  with  a  self-acting  spring 
or  a  thumb-screw.  Many  are  constructed  not  only  to  compress  the  lid  and 
thus  prevent  hemorrhage,  but  to  protect  the  eyeball  from  injury  during 
the  operation.  These  are  designed  with  a  broad  convex  plate  of  metal  or 
shell  that  forms  the  lower  blade,  and  is  so  shaped  as  to  fit  the  orbital  sur- 
face of  the  lid. 

Knapp's  Lid  Forceps,  as  exhibited  in  figure  2001,  consist  of  clamps  of 
the  spring  forceps  type,  the  under  blade  of  which  terminates  in  a  flat  disc 
not  unlike  a  thumb  nail  in  shape.  Usually  the  disc  is  from  20  to  25  milli- 
meters in  breadth  and  from  17  to  18  millimeters  antero -posteriorly.  This 
blade  is  intended  to  be  passed  into  the  orbital  space,  serving  not  only  as 
one  jaw  of  the  clamp  but  as  a  protection  to  the  eyeball  The  outer  blade 


ENTROPION. 


825 


is  long-,  slender  and  curved,  with  a  flattened  under  surface,  the  inner  mar- 
gin of  which  is  shaped  to  exactly  fit  around  the  outer  margin  of  the  metal 
or  shell  plate.  A  set  screw  enables  the  operator  to  securely  fasten  the  in- 


Figure  2001.    Knapp's  Lid  Forceps. 

strument   after   producing   compression.     Separate   instruments   are   con- 
structed for  each  eye,  and  are  known  as  rights  and  lefts. 


Figure  2002.    Snellen's  Lid  Forceps. 

Snellen's  Lid  Forceps,  as  shown  by  figure  2002,  differ  from  those  of 
Knapp  principally  in  that  the  shield  forming  an  extension  of  the  under 
blade  is  usually  made  from  metal.  The  breadth  of  the  shield  is  usually 
about  32  millimeters,  extending  flush  with  the  outer  margin  of  the  curved 
upper  blade.  They  are  also  made  in  rights  and  lefts. 


Figure  2003.    Noyes'  Lid   Forceps. 


Noyes'  Lid  Forceps,  as  represented  in  figure  2003,  differ  from  the  pat- 
terns previously  described  in  being  constructed  without  the  shield.  Both 
blades  are  alike  and  of  nearly  the  same  form  as  the  anterior  blade  of  the 
pattern  devised  by  Knapp.  The  breadth  of  the  blades  is  about  27  milli- 
meters outside  measurement.  They  may  be  used  upon  either  side. 


Figure  2004.    Desmarre's  Lid  Forceps. 

Desmarre's  Lid  Forceps,  according  to  figure  2004,  are  of  the  spring  pat- 
tern type,  but  with  an  oval  shield  surmounted  by  a  ring  of  corresponding 
size  and  shape.  The  long  diameter  of  the  shield  is  usually  about  26  milli- 
meters with  a  short  diameter  of  about  15  millimeters.  They  may  also  be 
used  upon  either  side. 

The  Cross-Bar  Lid  Forceps,  shown  in  figure  2005,  are  spring  forceps  of 
the  cross-action  type  terminating  in  T-shaped  jaws,  slightly  curved  with 


826 


OPHTHALMIC  SURGERY. 


the  concave  surface  outward.     The  jaws  are  usually  from  28  to  30  millime- 
ters in  length  with  the  inner  surfaces  serrated. 


Figure  2005.    Cross-Bar  Lid  Forceps. 


Schetterly's  Lid  Forceps,  as  disclosed  in  figure  2006,  are  of  the  plain 
spring  forceps  type,  constructed  with  cross-bar  jaws,  the  anterior  surfaces 


Figure  2000.     Schetterly's  Lid  Forceps. 

of  which  are  indented  with  several  slots  cut  alike  in  both  blades  and  in- 
tended as  guides  in  passing  sutures.  The  instrument  is  provided  with  a 
set  screw  for  maintaining  compression. 

Lid  Elevators. 

Lid  elevators,  called  by  different  authors,  holders,  plates,  shells,  etc., 
consist  of  broad  thin  sheets  of  metal,  rubber,  shell  or  other  material,  pro- 
vided with  round  margins  and  curved  to  fit  the  orbital  space.  They  are 
employed  to  render  the  lid  tense,  either  to  arrest  hemorrhage  or  to  protect 
the  globe  during  an  operation.  Usually  they  are  from  9  to  10  centimeters 
in  length,  with  small  and  large  ends,  the  former  from  22  to  25  and  the 
latter  about  30  millimeters  in  width. 


Figure  2007.    Jaeger's  Lid  Holder. 

Jaeger's  Lid  Holder,  as  exhibited  in  figure  2007,  and  as  usually  manu- 
factured, consists  of  two  thin,  hard  rubber  blades  slightly  curved  on  the 
edge.  The  outer  margins  on  the  convex  side  are  supplied  with  a  slight 
ridge  that  serves  to  keep  the  instrument  in  contact  with  the  lid.  Gener- 
ally the  instrument  is  ^j  of  an  inch  wide  at  its  narrow  and  i^  inches  wide 
at  its  broad  end. 


TRACHOMA. 

This  may  be  relieved  by  expression,  curettement,  excision  or  cataphor- 
csis  and  the  cautery. 


TRACHOMA. 


827 


Trachoma  by  Expression. 


This  operation  will  require: 

General  list  of  eye  instruments  described  on  page  803. 

Fixation  forceps  for  controlling  movement  of  globe,   figures   1930   to 

'933- 

Lid  everting-  forceps. 

Scarifier  for  incising  infiltrated  area. 
Trachoma  forceps  for  expressing  follicles. 

Lid  Everting  Forceps. 

Lid  everting  forceps  are  constructed  with  slender,  smooth  jaws  ar- 
ranged for  grasping  the  surface  of  the  lid  and  rolling  it  backward.  They 
may  be  either  of  the  self-closing  or  ring-handle  pattern. 


Figure  2008.    Gibson's  Lid  Everting  Forceps. 

Gibson's  Lid  Everting  Forceps,  as  illustrated  in  figure  2008,  are  spring 
forceps  of  the  crossing  type,  closed  by  compressing  the  centers  of  the  han- 
dles, and  secured  by  a  sliding  catch  with  which  any  degree  of  compres- 
sion may  be  obtained.  The  jaws  are  short  with  the  inner  margins  covered 
with  fine  longitudinal  serrations  that  afford  a  firm  grip  without  risk  of 
laceration. 


Figure  2009.    Weeks'  Lid  Everting  Forceps. 

Weeks'  Lid  Everting  Forceps,  as  represented  in  figure  2009,  are  of  the 
scissors  handle  type  closely  resembling  the  hemostatic  forceps  of  Pean. 
The  jaws  are  similar  in  construction  to,  but  longer  and  broader  than  the 
pattern  of  Gibson  previously  described. 

Scariflcators. 

These  are  shaped  like  a  round-pointed  bistoury  with  convex  edge. 
Formerly  instruments  were  employed  in  which  two  or  more  of  such  blades 
resting  side  by  side  and  in  close  proximity  to  each  other  were  attached  to 
one  handle. 


Figure  2010.    Desmarre's  Scarificator.  Figure  2011.    Von  Graefe's  Scarificator. 

Desmarre's  Scarificator,  as  represented  in  figure  2010,  is  a  slender  bis- 
toury with  a  convex  cutting  edge,  the  latter  extending  around  and  includ- 
ing the  point. 


828 


OPHTHALMIC  SURGERY. 


Von  Graefe's  Scarificator,  as  portrayed  in  figure  2011,  differs  from  the 
pattern  of  Desmarre  in  being  more  slender,  shorter  and  curved  on  the  edge 
to  the  arc  of  a  small  circle. 

Trachoma  Forceps. 

These  are  constructed  with  blades  arranged  to  squeeze  out  the  contents 
of  diseased  follicles  by  a  stripping  motion.  Noyes  recommends  the  use  of 
two  forceps,  each  pulling  or  drawing  away  from  the  other,  thus  stripping 
the  lids  of  any  granular  deposits.  It  is  usual  to  first  scarify  the  conjunc- 
tiva in  order  to  facilitate  the  escape  of  the  follicular  contents. 


Figure  2012.    Noyes'  Trachoma  Forceps. 


Noyes'  Trachoma  Forceps,  as  pictured  in  figure  2012,  are  of  the  plain 
spring  pattern,  the  blades  being  bent  near  the  tip  at  a  right  angle  with  the 
shaft  of  the  instrument.  This  curved  portion  is  usually  about  10  millime- 
ters in  length  by  4  millimeters  in  breadth.  The  inner  or  grasping  surfaces 
are  hollow  and  present  an  oval  depression  upon  either  side. 


Figure  2013.    Prince's  Trachoma  Forceps. 


Prince's  Trachoma  Forceps,  as  detailed  in  figure  2013,  are  of  the  spring 
pattern,  the  blades  terminating  in  small  oval  rings,  between  which  the  af- 
fected area  is  grasped,  squeezed  and  stripped  by  a  drawing  motion. 


Figure  2014.    Knapp's  Roller  Trachoma  Forceps. 

Knapp's  Roller  Trachoma  Forceps,  as  traced  in  figure  2014,  are  pro- 
vided with  two  bifurcated  spring  blades.  Shafts  pass  between  the  ends  of 
the  bifurcations,  upon  which  revolve  small  rollers  of  pinion  wire.  These 
rollers  are  thus  creased  longitudinally.  They  are  about  i  y2  millimeters  in 
diameter  by  8  millimeters  in  length.  The  arms  are  of  tempered  steel,  so 
adjusted  that  the  rollers  may  be  removed  for  cleansing. 

Trachoma  by  Curettement. 

This  operation  requires : 

General  list  of  eye  instruments  described  on  page  803. 

Lid  everting  forceps,  figures  2008  and  2009. 

Curette. 


Figure  2015.     Hebra's  Trachoma  Curette. 


Figure  2016.    Meyhoeffer's  Trachoma  Curette. 


Hebra's  Trachoma  Curette,  as  shown  in  figure  2015,  consists  of  a  small 
oval  spoon,  the  edges  of  which  are  ground  to  a  knife-like  sharpness.     It 


PTOSIS TARSORRAPHY — CANTHOPLASTY.  829 

may  usually  be  obtained  in  three  sizes,   4,  5   and  6  millimeters  in  long 
diameter,  respectively. 

Meyhoeffer's  Trachoma  Curette,  as  defined  in  figure  2016,  differs  from 
that  last  described  only  in  that  the  cutting  surfaces  are  circular.  It  may 
be  obtained  in  four  sizes,  2,  3,  4  and  5  millimeters  in  diameter  respectively. 

Trachoma  by  Excision. 

This  operation  requires: 

General  list  of  eye  instruments  as  described  on  page  803. 

Clamp  forceps,  figures  2001  to  2006. 

Scalpel,  figure  1980. 


Figure  2017.    Galezowsky's  Clamp  Forceps. 

Galezowsky's  Clamp  Forceps,  as  illustrated  in  figure  2017,  are  of  the 
spring-handle  pattern  with  short,  broad  blades,  the  latter  terminating  in 
V-shaped  jaws,  the  points  of  which  have  strong  mouse-teeth. 

Trachoma  by  Electro-Oataphoresis. 

The  destruction  of  trachomatous  tissues  by  electrical  osmosis  should  not 
be  confounded  with  electrolysis.  The  former  acts  on  the  well-known 
theory  that  electro-positive  medicaments  on  the  positive  pole  of  a  battery 
when  in  action  are  forced  or  carried  into  the  tissue  structure  by  repulsion. 
The  appliances  necessary  are  lid  everting  forceps,  as  shown  in  figures 
2008  or  2009,  a  small  protected  electrode,  and  the  medicament  to  be 
employed. 

PTOSIS. 

The  operation  for  ptosis  requires  the  following : 
Lid  elevator  for  retracting  lid,  figures  1917  to  1920. 
Lid  forceps  for  clamping  lid,  figures  2001  to  2005. 
Scalpel  or  other  knife  for  incision,  figure  1980. 
2  Tissue  forceps  for  dissection,  figure  1942. 
Scissors  for  enlarging  section,  figure  1994. 
Needles  for  sutures,  figures  1923  to  1926. 
Needle  holder,  figures  1927  to  1929. 
Silk  or  catgut,  figures  708  to  728. 

TARSORRAPHY. 

Tarsorraphy  requires  the  following  instruments: 
Lid  elevator  for  retracting  lid,  figures  1917  to  1920. 
Scalpel  or  other  knife  for  incisions,  figure  1980. 
Tissue  forceps  for  dissection,  figure  1942. 
Round-pointed  scissors  for  enlarging  section,  figure  1994. 
Needles  for  sutures,  figure  1923  to  1926. 
Needle  holder,  figures  1927  to  1929. 
Silk  or  catgut,  figures  708  to  728. 

OANTHOPLASTY. 

Canthoplasty  requires  the  following : 
General  list  of  eye  instruments  on  page  803. 


830  OPHTHALMIC  SURGERY. 

Probe-pointed  scissors  for  making  incision,  figure  1994. 

Lid  elevator  for  retracting  lid,  figures  1917  to  1920. 

Scalpel  or  other  knife  for  detaching  conjunctiva,  figure  1980. 

Needles  for  suture,  figures  1923  to  1926. 

Needle  holder,  figures  1927  to  1929. 

Silk  or  catgut,  figures  708  to  728. 


TRICHIASIS. 

Trichiasis  may  be  treated  by  epilation,   transplantation  or  electrolysis. 

Trichiasis  by  Epilation. 

This  operation  for  temporary  relief  is  usually  performed  with  forceps 
constructed  with  flat  jaws,  smooth  or  finely  serrated.  Care  should  be 
taken  that  the  hairs  are  not  broken  or  cut  by  the  forceps  jaws  in  the 
effort  to  remove  them. 


Figure  2018.     Plain  Epilating  Forceps. 


Figure  2019.    Bergh's  Epilating  Forceps. 


The  Plain  Epilating  Forceps,  as  shown  in  figure  2018,  are  of  the  spring 
pattern  and  have  jaws  provided  with  smooth  surfaces.  The  contact 
faces  are  shaped  like  half  an  oval  disc  divided  through  its  long  diam- 
eter. When  closed,  the  outer  surfaces  of  the  blade  terminals  should  be 
smooth  and  well  rounded 

Bergh's  Cilia  Forceps,  as  illustrated  by  figure  2019,  are  a  heavy  spring 
pattern  usually  about  4  inches  in  length  with  serrated  jaws.  The  terminal 
faces  of  the  forceps  blades  are  at  a  slight  angle  with  the  shaft  of  the  instru- 
ment. 


Figure  2020.    Piffard's  Epilating  Forceps. 

Piffard's  Epilating  Forceps,  as  may  be  seen  in  figure  2020,  are  also  of 
the  plain  spring  pattern.  Each  blade  is  provided  with  a  wing-shaped  pro- 
jection, forming  a  rectangular  jaw  3  by  4  millimeters  in  extent.  The  inner 
faces  of  the  jaws  are  finely  serrated,  thus  furnishing  a  good  grasping 
surface. 


Figure  2021.    Henry's  Epilating  Forceps. 

Henry's  Epilating  Forceps,  as  sketched  in  figure  2021,  consist  of  a 
spring  pattern  with  crossed  blades,  the  contact  surfaces  of  which  are  cov- 
ered with  crossed  serrations.  Pressure  on  the  handle  brings  the  jaws 
together. 


CHALAZION    CYSTS.  831 

Trichiasis  by  Transplantation. 

Trichiasis  by  transplantation  requires   the  following: 

General  list  of  eye  instruments  described  on  page  803. 

Lid  forceps  or  lid  elevators  for  retracting  lid,  figures  1917  or  2001. 

Scalpel  or  other  knife  for  incision,  figure  1980. 

Needles  for  sutures,  figures  1923  to  1926. 

Needle  holder,  figures  1927  to  1929. 

Silk  or  catgut,  figures  708  to  728. 

Trichiasis  by  Electrolysis. 

This  may  be    secured  by  employing  the  current  and  handles  described 
by  figures  481  and  482  for  the  removal  of  hair. 


CHALAZION  CYSTS. 

These  when  removed  from  the  conjunctival  side  require: 

General  list  of  eye  instruments  011  page  803. 

Eyelid  forceps  for  holding  and  everting  lid,  figures  2001  to  2009. 

Chalazion  forceps  for  encircling  tumor  and  restraining  hemorrhage. 

Von  Graefe's  knife,  needle  or  other  instrument  for  perforation  of  cyst, 
figure  1956. 

Curette  for  scooping  out  contents,  figures  2015  and  2016. 
Chalazion  cysts  when  removed  by  external  operation  require: 

General  list  of  eye  instruments  described  on  page  803. 

Lid  forceps  or  elevator  for  retracting  lid,  figures  1917  and  2001. 

Scalpel  or  other  knife  for  incision,  figure  1980. 

Sharp-pointed  scissors  for  use  in  connection  with  knife,  figure  1946. 

Hook  for  retracting  tumor,  figure  1950. 

Needles  for  sutures,    figures  1923  to  1926. 

Needle  holder,  figures  1927  to  1929. 

Silk  or  catgut,  figures  708  to  728. 

Chalazion  Forceps. 

These  consist  of  clamp-like  forceps,  usually  with  one  or  both  jaws  fen- 
estrated.  They  are  used  to  encircle  the  tumor  mass  and  make  pressure 
on  the  area  around  it. 


Figure  2022.    Ayer's  Chalazion  Forceps. 

Ayer's  Chalazion  Forceps,  shown  in  figure  2022,  are  the  most  popular 
patterns  of  chalazion  forceps.  Their  function  is  to  encircle  chalazia  before 
removal.  They  possess  the  advantage  that  they  restrain  hemorrhage  dur- 
ing the  operation. 


832  OPHTHALMIC  SURGERY. 


FOREIGN  BODIES. 

In  removing  foreign  substances  from  the  eye  the  surgeon  may  make 
use  of: 

Lance-pointed  needles. 

Curettes. 

Dressing  forceps. 

Probe  for  exploring. 

Electro-magnet. 

Spatulas. 

Iris  forceps. 

Scissors  with  fine  point  or  spud. 

Smooth  tooth -pick. 

Any  or  all  of  which  may  be  supplemented  by  a  lens  and  focal  illumi- 
nation. 

Spuds. 

These  consist  of  short,  flattened  blades  employed  to  scrape  away  or  dis- 
lodge a  foreign  substance. 


TRUAX  GREEME.-CO. 

Figure  2023.    Dix's  Spud.  Figure  2024.    Plain  Spud. 

Dix's  Spud,  as  portrayed  in  figure  2023,  is  an  elastic  steel  shank  with  a 
flattened  blade,  well-rounded  tip  and  curved  outer  margin.  It  is  particu- 
larly adapted  for  the  removal  of  substances  either  floating  or  loosely  em- 
bedded in  the  conjunctiva. 

The  Plain  Spud,  shown  in  figure  2024,  differs  from  the  pattern  of  Dix 
in  that  the  blade  is  flattened  throughout  nearly  its  entire  length  and  is 
rigid. 


Figure  2025.    Pocket  Spud  and  Needle. 

The  Pocket  Spud  and  Needle,  as  illustrated  by  figure  2025,  is  a  con- 
venient combination  for  the  extraction  of  foreign  bodies.  If  the  substance 
be  superficial,  the  spud  may  be  used ;  but  if  embedded  in  the  cornea,  the  lat- 
ter may  be  first  anesthetized  by  the  instillation  of  a  few  drops  of  a  solu- 
tion of  cocaine,  four  per  cent,  being  generally  used.  Two  or  three  instilla- 
tions are  usually  sufficient,  after  which  the  needle  end  may  be  used  to 
loosen  or  pick  out  the  foreign  body,  care  being  taken  not  to  perforate  the 
anterior  chamber. 

The  Electro-Magnet. 

The  electro-magnet  consists  of  a  small  cylindrical  instrument  provided 
with  a  slender  tip  and  means  for  controlling  the  magnetic  or  attracting 
force.  The  latter  is  generated  by  whatever  number  of  cells  may  be  in- 
cluded in  the  circuit. 

The  Electro-Magnet  is  displayed  full  size  in  figure  2026.  It  is  em- 
ployed for  the  removal  of  small  particles  of  iron  and  steel  from  the  cornea 


DISEASES  OF   LACHRYMAL  DUCT   AND  SAC. 


833 


and  chambers  of  the  eye.  Workmen  in  factories  and  machine  shops  are 
frequently  annoyed,  and  in  many  cases  their  eyesight  is  imperiled  or 
destroyed,  by  small  pieces  of  metal  that  become  detached  from  revolving 
masses.  If  it  be  superficial,  a  plain  horse-shoe  magnet  will  usually  remove 
it  by  attraction ;  but  if  the  particle  be  deeply  embedded,  the  more  powerful 


Figure  2026.    Electro-Magnet. 

electro-magnet  should  be  employed.  It  may  be  used  by  connecting  the 
conducting  cords  with  the  poles  of  one  or  more  battery  cells  and  bringing 
the  slender  tip  near  to  or  in  contact  with  the  particle.  If  the  latter  be 
deeply  embedded  in  the  cornea,  it  may  be  necessary  to  loosen  it  with  a 
spud  or  other  instrument.  If  the  metallic  body  has  penetrated  either 
chamber,  it  will  be  necessary  to  introduce  the  tip  into  the  track  of  the 
metal,  when,  if  contacted,  it  may  usually  be  removed. 


Figure  202~.    Noyes'  Lens,  with  Finger  Attachment. 


Figure  2028.    Wood's  Frontal  Lens. 


Noyes'  Lens  with  ringer  attachment  includes  a  small  clamp  provided 
with  a  short  bar,  that  is  not  only  attached  so  as  to  provide  universal  move- 
ments, but  with  an  extension  by  which  it  may  be  lengthened.  It  is  pro- 
vided with  a  semi-circular  clip,  constructed  to  hold  a  lens  \y2  inches  in 
diameter.  While  any  focus  may  be  employed,  one  of  two  inches  is  gener- 
ally preferred.  It  is  delineated  in  figure  2027. 

Wood's  Frontal  Lens,  as  depicted  in  figure  2028,  differs  from  the  pat- 
tern of  Noyes  in  that  it  is  attached  to  a  headband.  The  adjustment  is 
such  that  it  may  be  placed  in  any  desired  position. 


DISEASES  OF  LACHRYMAL  DUCT  AND  SAC. 

This  may  require  some  of  the  following: 

Pipette  for  introduction  of  cocaine. 

Probes  for  ascertaining  condition  of  and  dilating  canal. 


834 


OPHTHALMIC  SURGERY. 


Dilators  for  enlarging  canal. 

Knife  for  slitting  canaliculi. 

Knife  for  incision  of  stricture. 

Directors  for  guiding  the  knife. 

Styles  or  canulas  for  maintaining  patency  of  canal. 

Syringes  for  irrigation. 

Cocaine  Pipettes. 

These  are  employed  to  secure  local  anesthesia.     They  differ  from 
dinary  pipettes  in  being  provided  with  more  delicate  tips. 


or- 


Figure  2029.    Prince's  Pipette. 

Prince's  Pipette,  as  shown  by  figure  2029,  is  a  useful  instrument  for  the 
introduction  of  a  solution  of  cocaine  into  the  lachrymal  canal.  The  cylinder 
is  made  of  glass  and  the  point  is  preferably  of  platinum  so  that  it  may  be 
quickly  sterilized  by  passing  it  through  a  flame. 

Lachrymal  Probes. 

Probes  for  use  in  the  lachrymal  ducts  are  usually  of  metal,  silver  being 
preferred.  Aluminum  is  recommended  for  the  larger  sizes  by  some  authors, 
but  experience  has  shown  that  this  metal  is  unfit  for  such  purposes.  This 
subject  is  fully  discussed  on  page  15. 


Figure  2030.    Bowman's  Lachrymal  Probes. 

Bowman's  Lachrymal  Probes,  as  depicted  in  figure  2030,  comprise  a 
series  of  straight  rods  of  silver  wire,  each  composed  of  two  pieces  of  differ- 
ent size.  A  set  of  four  instruments  thus  furnishes  eight  sizes  of  probes, 
graduated  from  %  of  a  millimeter  to  i  y2  millimeters  in  diameter.  In  the 
center  of  each  instrument  a  flanged  projection  furnishes  a  grasp  for  the 
fingers  and  space  for  numbering.  That  they  may  be  of  the  required 
stiffness,  they  should  be  made  from  sterling  silver. 


Figure  2031.    Williams'  Lachrymal  Probe. 

Williams'  Lachrymal  Probes,  as  portrayed  in  figure  2031,  differ  from  the 
pattern  of  Bowman  in  that  they  are  slightly  bulb  pointed  and  have  flexible 
necks.  While  they  are  firm  enough  for  introduction,  yet  they  are  suffi- 
ciently flexible  to  enable  them  to  be  curved  and  passed  through  sinuous 
canals. 


DISEASES  OF  LACHRYMAL  DUCT  AND  SAC. 


835 


Theobold's  Lachrymal  Probes,  as  indicated  in  figure  2032,  comprise  a 
set  of  eight  double-ended  instmments,  slightly  curved  throughout  their 
entire  length,  each  provided  with  a  flange  in  the  center,  as  previously  de- 


Figure  2032.    Theobold's  Lachrymal  Probes. 

scribed.   They  vary  in  diameter  from  ^  of  a  millimeter  to  4  millimeters,  each 
succeeding  number  representing  an  additional  %  millimeter  in  diameter. 


Figure  2033.    Anel's  Lachrymal  Probe. 

Anel's  Lachrymal  Probe,  as  set  forth  in  figure  2033,  consists  of  a  delicate 
silver  rod  yj  to  %  a  millimeter  in  diameter,  and  about  3^  inches  in  length, 
terminating  in  a  bulbous  tip.  They  are  usually  constructed  of  pure  silver, 
that  they  may  be  readily  curved  as  desired. 


Figure  2034.    Noyes'  Lachrymal  Probe. 

Noyes'  Lachrymal  Probe,  as  represented  in  figure  2034,  differs  prin- 
cipally from  the  pattern  of  Anel  in  being  much  heavier  and  a  trifle  longer. 
It  is  about  \y<z  millimeters  in  diameter,  4  inches  in  length  and  has  a  long 
olive- shaped  tip. 

Lachrymal  Dilators. 

Dilators  usually  consist  of  conical  rods,  by  the  introduction  of  which  the 
canal  may  be  enlarged. 


Figure  2035.    Weber's  Graduated  Dilator. 

Weber's  Graduated  Dilator,  as  illustrated  in  figure  2035,  consists  of  two 
conical  arms  attached  to  an  oval  disc,  the  latter  serving  as  a  finger-piece,  or 
hold  for  grasping  the  instrument.  The  arms  of  the  instrument  are  gradu- 


Figure  2036.    Williams'  Silver  Dilator. 


ated,  circles  being  cut  to  show  the  diameter  at  the  point  of  marking.  The 
smaller  of  the  two  arms  is  probe-pointed,  that  it  may  be  the  more  easily 
introduced  into  narrow  openings.  The  larger  arm  is  a  true  cone  equal  in 
size  at  its  base  to  a  No.  16  Bowman's  probe. 


836 


OPHTHALMIC   SURGERY. 


Williams'  Dilator,  as  shown  in  figure  2036,  is  a  slender  shaft,  each  end 
of  which  terminates  in  an  olive-shaped  enlargement,  the  latter  forming  a 
slender  cone  with  the  apex  directed  outward.  One  end  forms  a  dilator  of 
large,  the  other  one  of  small  size. 

Lachrymal  Canaliculus  Slitting. 

This  may  require  the  general  list  of  instruments  described  on  page  803. 
The  one  essential  appliance  for  lateral  incision  is  a  special,  slender  probe- 
pointed  knife.  This  form  is  necessary,  as  it  facilitates  the  passage  of  the 
blade  through  the  punctum  and  into  the  canaliculus. 

Canaliculus  Knives. 

Weber's  Straight  Canaliculus  Knife,  the  shape  of  which  is  made  clear 
by  figure  2037,  has  a  slender  blade  about  ij^  millimeters  wide,  with  a  cut- 


Figure  2037.     Weber's  Straight  Canali-  Figure  2033.     Liebrich's  Canaliculus  Knife. 

culus  Knife. 

ting  edge  about  17  millimeters  in  length,  terminating  in  a  slender  point 
slightly  curved  downward. 

Liebrich's  Canaliculus  Knife,  as  delineated  in  figure  2038,  is  a  long  slen- 
der shank  ending  in  a  narrow  triangular  blade  about  3  millimeters  in 
width  at  its  apex,  terminating  in  a  straight  bulbous  point,  and  with  a  cut- 
ting surface  about  20  millimeters  in  extent. 


Figure  2039.     Noyes'-Stilling's  Canali- 
culus Knife. 


Figure  2040.     Noyes'  Canaliculus  Knife. 


Noyes'-Stilling's  Canaliculus  Knife,  as  outlined  in  figure  2039,  consists 
of  a  long  sickle-shaped  blade  3  millimeters  wide  at  its  base  with  a  cutting 
surface  about  15  millimeters  in  extent,  the  whole  terminating  in  a  sharply- 
curved  probe  point. 

Noyes'  Canaliculus  Knife,  as  shown  in  figure  2040,  differs  from  the  pat- 
tern of  Weber  in  the  construction  of  the  point,  which,  in  this  design,  is  bent 
downward  at  an  angle  of  about  135°. 


Figure  2041.     Bowman's  Canaliculus  Knife.  Figure  2042.    Weber's  Curved  Canaliculus  Knife. 

Bowman's  Canaliculus  Knife,  as  exhibited  in  figure  2041,  consists  of  a 
slender,  slightly  curved  blade  about  i^  millimeters  in  width,  terminating 
in  a  fine  curved  bulbous  point. 

Weber's  Curved  Canaliculus  Knife,  as  displayed  injigure  2042,  consists 
of  a  blade  curved  throughout  its  entire  length,  about  2  millimeters  in  width 
and  with  a  cutting  surface  about  20  millimeters  long.  It  is  probe-pointed 
and  the  tip  curved. 

Lachrymal  Stricture  Knife. 

Knives  for  incising  cicatricial  bands  should  have  short  blades  mounted 
on  long  slender  shanks.  In  some  patterns  the  latter  are  flexible,  that  they 
may  be  shaped  to  conform  to  various  conditions. 


DISEASES  OF  LACHRYMAL  DUCT  AND  SAC. 


83T 


Agnew's  Lachrymal  Stricture  Knife,  as  illustrated  in  figure  2043,  is  a 
long  shank  terminating  in  a  slender  scalpel-shaped  blade,  having  a  cutting 
edge  about  1 2  millimeters  in  extent,  with  a  width  at  its  broadest  part  of 


Figure  2043.    Agnew's  Lachrymal  Stricture  Knife. 

about  2  millimeters.     The  shank  should  be  flexible.     It  may  be  obtained' 
with  a  straight  or  an  angular-bent  point. 

Noyes'  Lachrymal  Stricture  Knife,  as  outlined  in  figure  2044,  has  a  short 
triangular  blade  about  10  millimeters  in  length  with  a  breadth  at  the  base 
of  the  triangle  of  about  3  ^  millimeters.  The  instrument  terminates  in  a 
small  bulbous  point.  The  shank  is  soft  and  flexible  and  the  instrument  may 
be  easily  bent  to  any  desired  form. 


Figure  2044.    Noyes'  Lachrymal  Stricture  Knife. 


Figure  2045.     Thomas'  Lachrymal 
Stricture  Knife. 


Thomas'  Lachrymal  Stricture  Knife,  as  set  forth  in  figure  2045.  ^s  a 
stronger  and  heavier  pattern  than  those  before  described.  The  blade  is 
about  8  millimeters  in  length,  terminating  in  a  long  probe-point,  well  shown 
by  the  illustration. 

Lachrymal  Directors. 

Directors  may  be  employed  to  assist  in  locating  the  duct  and  guiding  the 
point  of  the  knife.  They  usually  consist  of  a  slender  silver  rod,  provided 
with  a  groove  that  serves  as  a  guide.  By  forming  the  end  opposite  to  the 
guide  into  a  bulb-pointed  probe  the  instrument  may  be  made  to  answer  a 
two-fold  purpose. 


Figure  2046.    Bowman's  Director. 

Bowman's  Director,  as  represented  by  figure  2046,  is  a  slender  silver 
guide  about  il/2  millimeters  in  diameter,  terminating  in  a  silver  probe 
closely  resembling  the  pattern  of  Anel  before  described.  Its  length  is  about 
4  inches. 

Lachrymal  Styles  and  Canulas. 

After  operation  the  opening  in  the  canal  may  be  rendered  permanent  by 
the  use  of  plugs  called  styles  or  canulas.  These  may  be  solid  or  hollow, 
and  made  from  lead,  gold  or  silver,  the  latter  being  preferred. 


Figure  2047.     Prince's  Perforated  Styles, 
Right  and  Left. 


Figure  2048.     Lachrymal  Styles. 


Prince's  Perforated  Styles,  as  shown  by  figure  2047,  are  employed  in 
the  treatment  of  lachrymal  fistula  and  suppurative  dacrocystitis.  The  cork- 
screw-shaped  end  facilitates  their  removal.  They  are  manufactured  in 
sizes  corresponding  to  Bowman's  prcbes.  They  are  of  silver,  soft  and  flex- 


838 


OPHTHALMIC  SURGERY. 


ible,  that  the  curve  may  be  modified  to  conform  to  individual  requirements. 
Their  length,  excluding  the  curved  portion,  is  usually  about  \y2  inches. 

The  Solid  Lachrymal  Styles,  delineated  in  figures  2048  and  2049,  illus- 
trate some  of  the  more  useful  patterns  of  these  instruments. 


Figure  3049.     Lachrymal  Styles. 

The  Lachrymal  Canulas,  depicted  in  figure  2050,  are  some  of  the  more 
common  forms  in  use.     They  may  be  obtained  of  various  diameters  and 


Figure  8050.     Lachrymal  Canulas. 


Figure  2051.    Taylor's  Lach- 
rymal Canula. 


lengths.     They  are  used  to  sustain  a  free  tear-drainage  from  the  eye  through 
the  nasal  duct. 

Taylor's  Lachrymal  Canula,  as  portrayed  in  figure  2051,  is  a  metal  tube 
about  iy&  inches  in  length,  bent  at  a  right  angle,  the  short  arm  being  about 
y&  of  an  inch  in  length.  This  arm  is  provided  with  a  lateral  slit 
upon  both  sides,  leaving  a  sort  of  duck-bill  spout  with  upper  and  lower 
blades,  both  of  which  should  rest  beneath  the  surface  of  the  lids,  hidden 
from  view  within  the  passage.  The  slit  prevents  the  soft  tissues  from  clos- 
ing the  tube  opening,  thus  facilitating  the  passage  of  tears.  Its  author 
claims  that  this  form  may  be  worn  indefinitely  without  the  slightest  annoy- 


ance. 


Lachrymal  Syringes. 


These  may  be  obtained  of  various  forms  and  materials.  The  barrels  may 
be  either  of  rubber,  glass  or  metal,  the  two  latter  being  usually  preferred. 
The  needles  may  be  of  steel,  either  sharp  or  blunt,  of  silver  or  of  gold,  either 
curved  or  straight.  The  following  may  be  found  in  stock  with  most  dealers 
and  are  the  ones  in  most  common 


use 


Figure  2052.    Agnew's  Lachrymal  Syringe. 

Agnew's  Lachrymal  Syringe,  as  illustrated  in  figure  2052,  does  not  differ 
in  general  form  from  those  employed  for  hypodermic  use.  The  cylinder  is 
large  and  with  metal  attachments.  The  needles  are  of  silver,  two  in  num- 
ber and  have  blunt  points.  They  may  be  curved  to  suit  various  conditions. 

Anel's  Lachrymal  Syringe,  as  sketched  in  figure  2053,  consists  of  an  all- 
metal  cylinder  provided  with  finger  rings,  by  which  the  instrument  may  be 
firmly  held.  The  needles  are  three  in  number  with  strong  shanks,  two  of 


EXAMINATIONS. 


839 


them  terminating  in  soft  slender  tips.  This  enables  the  operator  to  change 
the  curve  of  the  needle  when  desired.  As  found  in  the  market,  one  needle 
is  straight,  one  full  curved  and  one  half  curved. 


Figure  2053.    Ariel's  Lachrymal  Syringe. 

EXAMINATIONS. 

Examinations  of  the  eye  often  require  delicate  and  complex  apparatus, 
in  the  proper  manipulation  of  which  no  small  amount  of  skill  is  demanded. 
The  instruments  necessary  may  be  classified  as  those  for: — Illumination; 
determining  size  of  pupil,  acuteness  of  vision,  degree  of  light  perception, 
color  sense  and  strength  of  extrinsic  eye  muscles ;  measuring  field  of  vision 
and  accommodation ;  and  measuring  and  correcting  errors  of  refraction. 

Illumination. 

Examination  and  external  illumination  of  the  eye  may  be  secured  by 
the  use  of  a  plain  convex  lens  having  a  focus  of  2  or  3  inches  and  a 
source  of  illumination  such  as  an  Argand  burner  or  similar  light. 

Plain  Lenses. 


Figure  2054.    Plain  Convex  Lens.  Figure  2055.    Corneal  Loupe. 

The  Plain  Convex  Lens,  shown  in  figure  2054,  Usually  has  a  diameter  of 
from  i>2  to  2  inches,  and  may  be  procured  with  a  focus  of  2,  3  or  more 
inches.  They  may  be  procured  with  or  without  handles. 

The  Corneal  Loupe,  illustrated  by  figure  2055,  comprises  a  mounted  lens 
or  lenses,  used  singly  or  two  or  more  in  combination,  by  which  the  cornea 

may  be  strongly  magnified. 

Ophthalmoscopes. 

Examination  of  the  interior  of  the  eye  may  be  made  with  an  ophthalmo- 
scope. This  consists  of  an  object  lens  and  a  small  mirror  mounted  on  a 
suitable  handle  and  provided  with  a  central  opening,  through  which,  when 
the  eye  is  illuminated  by  the  reflected  mirror  light,  the  surgeon  may  ex- 


340  OPHTHALMIC  SURGERY. 

amine  the  exposed  area.  They  are  employed  to  determine  the  anomalies 
of  the  eye,  for  illumination  of  the  fundus,  and  as  an  aid  in  diagnosing  cer- 
tain organic  diseases.  The  mirror  may  be  either  plane  or  concave,  and 
while  both  accompany  some  patterns  of  instruments,  the  latter  is  usually 
preferred.  In  many  the  mirror  is  hinged,  so  that  it  may  be  tilted  to  either 
side,  thus  enabling  the  surgeon  to  reflect  oblique  rays  into  the  eye  without 
turning  the  face  of  the  mirror  away  from  the  patient.  This  is  an  advantage, 
for  holding  the  mirror  at  any  other  than  a  right  angle  with  the  line  of  vis- 
ion lessens  the  lateral  sight  diameter  of  the  mirror  opening,  thus  shutting 
out  much  of  the  necessary  field  of  vision.  Nearly  all  are  constructed  with 
a  circular  disc  in  which  is  mounted  a  series  of  minute  lenses  so  adjusted  that 
the  surgeon  may  rotate  any  one  of  them  in  front  of  the  small  circular  open- 
ing, thus  enabling  him  to  study  and  modify  abnormal  refractive  conditions. 

Many  modern  instruments  contain  two  discs  that  may  be  used  singly 
or  in  combination,  thus  admitting  of  the  formation  of  a  large  number 
of  varying  degrees  of  strength.  Each  instrument  should  be  accompanied  by 
a  plain  lens  for  focal  and  oblique  illumination. 

In  numbering  the  powers  of  the  lenses  in  an  ophthalmoscope  there  are  two 
systems  in  use;  namely,  the  English  and  the  metric.  The  latter  is  being 
rapidly  adopted  and  at  an  early  date  will,  no  doubt,  render  obsolete  the  in- 
convenient English  inch  system.  In  the  metric  system  the  unit  of  length 
is  one  meter,  which  is  equal  to  100  centimeters,  1,000,  millimeters,  or, 
approximately,  40  English  inches. 

The  dioptric  or  metric  method  of  calculating  the  result  of  a  combination 
of  lenses,  either  to  increase  or  decrease  the  length  of  focus  or,  in  other 
words,  the  power,  is  a  simple  mental  operation,  whereas  the  English  inch 
system  requires  extensive  calculation.  Some  of  the  more  common  grades  of 
ophthalmoscopes  exhibit  both  graduations,  giving  the  equivalent  of  the  diop- 
trics in  inches  at  a  glance,  and,  in  some  of  these  instruments,  to  facilitate 
calculation,  a  dioptry  is  assumed  to  be  equal  to  36  inches.  A  dioptry  cor- 
responds to  a  meter,  which  is  equal  to  39.37  inches.  For  practical  purposes 
it  may  be  called  40  inches,  but  not  36. 

With  a  view  of  readily  estimating  the  relation  between  the  two  scales, 
it  is  well  to  know  that  the  product  of  the  dioptries  multiplied  by  the  equiv- 
alent in  inches  is  always  40,  and  that  40  inches  are  equal  to  i  dioptry.  It 
therefore  follows  that  dioptries  and  inches  are  in  an  inverse  ratio.  In 
dioptries,  the  higher  the  number  indicating  the  focus  the  greater  the  power ; 
in  inches,  the  higher  the  number,  the  less  the  power.  For  example,  5 
inches=8  dioptries,  and  the  product  of  5x8  is  40.  16  inches=2.5o  dioptries, 
and  the  product  of  16x2.50  is  40,  and  so  on  through  the  series  of  numbers. 

The  following  is  a  comparative  list  of  the  dioptric  and  inch  system : 

Inches.  Dioptries.  Inches.    Dioptries.  Inches.    Dioptries. 

160  0.25  16  2.50  51^  7.50 

80  0.50  14  2.75  5  8.00 

60  0.67  13  3.00  4^  9.00 

5°  °-75  12  3.33  4  10.00 

40  i. oo  ii  3.50  3^4  10.50 

36  i. ii  10  4.00  3^  n.oo 

3°  *-25  9  4-5°  2>l/i  I2-°° 

24  i-5°  5.00  3  13.00 

22  !-75  7  5-5°  *Y\  14-0° 

20        2.00  6^        6.00  2^         l6.00 

18     2.25  6         6.50  2%      18.00 

2  2O.  OC 


OPHTHALMOSCOPES. 


841 


Liebrich's  Ophthalmoscope,  as  exhibited  in  figure  2056,  is  a  plain  circular 
mirror  about  i^  inches  in  diameter  provided  with  a  central  opening  similar 
to  the  reflectors  employed  in  laryngoscopes.  A  double-hinged,  semi- circular 
clip  is  attached  to  the  rim  of  the  mirror  frame.  This  is  grooved  to  receive 


Figure  2056.    Liebrich'e  Ophthalmoscope.  Figure  2057.    Loring's  7- Lens  Ophthalmoscope. 

such  lenses  as  the  surgeon  may  select  for  studying  and  modifying  refracth  c 
conditions.  Usually,  each  instrument  is  supplied  with  one  convex  and  four 
concave  lenses  for  this  purpose.  Two  magnifying  lenses  of  2  and  3-inch 
focus,  respectively,  also  form  a  portion  of  the  outfit. 


Figure  2058.    Loring's  15-Lens  Ophthalmoscope. 


Figure  2059.    Knapp's  23-Lens  Ophthalmoscope. 


Loring's  7-Lens  Ophthalmoscope,  as  portrayed  in  figure  2057,  consists 
of  a  small  circular  mirror,  usually  i^  inches  in  diameter,  mounted  in  a 
metallic  frame,  to  the  back  of  which  a  rotating  disc  with  eight  openings  is 
attached  by  a  screw  pivot.  Three  of  the  openings  are  supplied  with  convex 
and  four  with  concave  lenses,  while  the  eighth  is  blank.  Any  one  of  these 


842 


OPHTHALMIC  SURGERY. 


apertures  may  be  carried  by  rotation  in  front  of  the  central  mirror  opening 
and  the  lens  thus  brought  into  use.  Two  magnifying  glasses  and  a  handle 
complete  the  outfit. 

Loring's  is-Lens  Ophthalmoscope,  as  pictured  in  figure  2058,  differs  from 
the  pattern  last  described  in  that  the  revolving  plate  contains  eight  concave 
and  seven  convex  lenses. 

Knapp's  23-Lens  Ophthalmoscope,  as -exhibited  in  figure  2059,  differs 
from  the  pattern  of  Loring  last  described  in  containing  twelve  concave  and 
eleven  convex  mirrors.  In  addition,  it  is  provided  with  a  spring  stop,  by 
which  a  central  adjustment  of  each  lens  directly  in  front  of  the  mirror 
opening  may  be  secured.  The  disc  is  provided  with  two  sets  of  numbers. 
Unlike  the  instruments  previously  described,  the  disc  is  covered  by  a  plate 
that  not  only  insures  protection  of  the  lenses  but  serves  to  keep  them  clear 
and  bright.  '  It  is  also  provided  with  a  handle  and  two  magnifying  lenses. 


Figure  2060.    Loring's  15-Lens  Ophthalmoscope  with  Quadrant. 

Loring's  is-Lens  Ophthalmoscope  with  Quadrant,  as  portrayed  in  figure 
2060,  differs  from  the  patterns  previously  described  in  being  provided  with 
a  segment  of  a  disc  by  which  any  one  of  four  additional  lenses  may  be 
placed  in  combination  with  any  one  of  the  fifteen  in  the  circular  plate. 
The  latter  contains  fifteen  lenses,  eight  concave  and  seven  convex.  The 
disc  contains  two  concave  and  two  convex,  the  whole  forming  a  series  of 
forty-seven  foci,  twenty-four  of  which  are  minus  and  twenty-three  plus. 
These  may  be  further  enlarged  by  using  what  are  termed  "half  numbers." 
This  instrument  is  provided  with  a  tilting  mirror,  the  advantages  of  which 
have  been  previously  mentioned.  When  not  in  use,  the  quadrant  may  be 
rotated  and  concealed  beneath  a  portion  of  the  back  cover.  One  or  two 
magnifying  lenses  are  usually  provided  with  each  instrument. 

Morton's  Ophthalmoscope,  as  pictured  in  figure  2061,  contains  twenty-nine 
lenses,  seventeen  concave  and  twelve  convex,  which  are  arranged  to  follow 
an  oval  endless  groove,  along  which  they  are  propelled  by  a  circular  driving 
wheel  attached  to  the  rear  of  the  lower  border  of  the  instrument.  This  wheel 
serves  to  propel  the  lenses  without  necessitating  the  removal  of  the  instru- 


EYE  MODELS. 


843 


ment  from  its  position  before  the  eye  of  the  patient.  It  is  provided  with 
three  mirrors,  plain,  concave  and  tilting,  the  latter  of  short  focus.  The 
driving  wheel  is  provided  with  a  number  of  discs  that  are  regularly  num- 
bered, the  whole  forming  a  serviceable  pupillometer.  A  rotating  disc  placed 


Figure  2061.    Morton's  Ophthalmoscope. 


Figure  2062.    Ophthalmo-Phantome. 


in  the  back  and  at  the  center  of  the  instrument  is  regularly  numbered,  the 
upper  figure  determining  the  lens  that  is  opposite  the  peep  hole.  A  circular 
quadrant  containing  four  mirrors  supplies  all  the  advantages  offered  by  the 
pattern  of  Loring.  It  is  supplied  with  a  handle  and  one  magnifying  glass. 

Eye  Models  for  Practice. 

Education  in  the  use  of  the  ophthalmoscope  may  be  advanced  by  prac- 
tice with  some  form  of  model  that  assimilates  in  a  measure  the  conditions 
encountered  when  making  examinations  of  the  natural  eye.  The  various 
appliances  in  use  are  known  as  phantomes,  and  skiascopic  and  ophthalmo- 
scopic  eyes,  etc. 


970. 

Figure  2063.    Thorington's  Skiascopic  Eye. 


Figure  2064.    Thorington's  Skiascopic 
Eye  on  Stand. 


The  Ophthalmo-Phantome,  outlined  in  figure  2062,  consists  of  a  mask 
imitative  of  the  face.  The  orbit  of  the  phantome  is  mechanically  arranged 
to  grasp  and  hold  the  eye  of  an  animal,  and  adjusted  to  artificially  assimi- 


844  OPHTHALMIC   SURGERY. 

late  the  condition  of  the  natural  eye  under  an  operation.  There  is  no  in- 
vention better  adapted  to  the  education  of  the  hand  for  operating  on  the 
eye. 

Thorington's  Skiascopic  Eyes,  as  exhibited  in  figures  2063  and  2064, 
differ  from  each  other  in  that  the  first  is  inexpensively  manufactured  from 
paper,  while  the  second  is  constructed  from  brass  and  mounted  on  a  neat 
yet  firm  stand.  It  presents  the  shadow  test  as  an  accurate  method  of  ob- 
taining the  exact  refraction  of  an  eye  under  the  influence  of  a  cycloplegic. 
It  consists  of  two  cylinders,  one  telescoping  within  the  other.  Both  pre- 
sent dead-black  inner  surfaces.  The  smaller  is  closed  at  its  distal  end,  and 
on  its  inner  surface  is  covered  with  a  colored  lithograph  of  the  normal  eye. 
The  larger  cylinder  is  closed  at  its  proximal  end  except  a  central  circular 
opening  10  millimeters  in  diameter  in  which  a  20  dioptry  lens  is  mounted. 
Its  outer  surface  is  covered  with  a  colored  lithograph  of  the  fundus,  the 
pupil  represented  as  dilated  to  the  size  of  the  opening.  In  addition  to  this, 
the  upper  border  is  graduated  with  the  degree  marks  similar  to  those  on 
the  trial  frame.  It  is  further  arranged  with  supports  for  trial  lenses,  that 
they  may  be  used  during  examinations.  Other  features  are  included,  the 
whole  answering  admirably  for  the  beginner  in  ophthalmology. 

Determining  Size  of  Pupil. 

The  size  of  the  pupil  may  be  determined  by  the  use  of  special  instru- 
ments called  pupillometers. 

Pupillometers. 

These  consist  of  caliper-like  instruments  or  a  series  of  circular  openings, 
by  either  of  which  means  the  diameter  of  the  pupil  may  be  deter- 
mined. 


Figure  2065.    Randall's-Follin's  Pupillometer. 

Randall's-Follin's  Pupillometer,  as  exhibited  in  figure  2065,  consists  of  a 
small  plate  or  circular  opening  of  varying  sizes,  each  numbered  according  to 
the  regular  scale.  In  use  this  plate  may  be  held  close  to  the  patient's  eye, 
the  opening  to  the  pupil  contracted,  and  changes  made  until  that  opening 
is  found  which  corresponds  in  size  to  the  pupillary  area. 

Acuity  of  Vision  or  Form  Sense. 

Acuity  of  vision  or  form  sense  may  be  determined  by  test  types,  those 
of  Snellen  being  most  commonly  employed.  They  consist  of  a  series  of 
black  letters  on  a  white  ground  so  arranged  that  the  smallest  image  which 
the  retina  can  distinguish  may  be  determined. 


DETERMINATION    OF    ACUITY    OF    VISION. 


Snellen's  Test  Types  for  Acuity  of  Vision,  as  displayed  in  figure  2067, 
consist  of  a  series  of  cards  upon  which  are  printed  various  letters  of  the 
alphabet,  some  of  which  are  usually  reversed  or  turned  half  to  the  right  or 
left.  They  are  best  understood  by  studying  the  illustration. 


HI 

B 

— 

f. 

ill    cr 

•pi 

.. 

c. 

Jj 

C  P  HE  I.  O 
C  O  F  B  E 

L  E'R  F 

E  UJ  3 

T  B  R 

D  Z  T 

m  LU  E  3 

FEED 

B  F 

m  m  3  E  uj 

E  T  L  r  N 

E 

3  E  U  3  fl)  U 

P  7,  E  O  B  0 

0    I    T   Z   B   D   K 

Figure  2067.     Snellen's  Test  Types. 

Determination  of  Color  Sense. 

Ability  to  distinguish  colors  one  from  another  in  the  detection  of  color- 
blindness may  be  determined  by  several  methods,  that  of  Holmgren  by 
the  use  of  colored  yarns  being  generally  preferred.  Eldridge-Green,  in  the 


Figure  2068.     Holmgren's  Worsteds. 

examination  of  sailors  and  railroad  employes,  uses  an  apparatus  that  con- 
sists of  a  lantern  and  a  series  of  colored  slides.  They  are  employed  to  de- 
termine whether  or  not  the  candidate  can  discriminate  between  red,  green 
and  white  lights. 

Holmgren's  Worsteds,  which  are  illustrated  in  figure  2068,  consist 
of  a  collection  of  various  colored  yarns  in  skeins,  each  about  10  centi- 
meters long  and  of  the  thickness  of  the  finger.  Besides  the  spectral  colors  of 
red,  orange,  yellow,  green,  blue  and  violet,  different  shades  of  mixed 
colors,  such  as  purple,  rose  and  gray  are  included. 

With  these  normal  color  sense  may  be  quickly  determined  or  the  extent 


OPHTHALMIC  SURGERY. 


of  color-blindness  decided.  When  uneducated  color  perception  is  sus- 
pected, a  special  elementary  color  chart  may  be  employed.  Frequently 
persons  who  have  applied  for  positions  requiring  keen  color  sense,  and  have 
been  rejected,  have  been  educated  in  this  manner  and  the  supposed  defect 
corrected. 

Strength  of  Extrinsic  Eye  Muscles. 

The  examination  of  the  extrinsic  ocular  muscles  is  made  by  placing 
before  one  eye  some  apparatus  that  will  disassociate  the  images  of  the  two 
eyes.  Various  appliances  have  been  devised  for  this. purpose,  the  most 
common  among  which  are  the  Maddox  rod,  the  Maddox  double  prism 


Figure  2069.    Maddox'  Test  for  Heterophoria. 


Figure  2069A.    Maddox'  Double  Prism. 


and  a  single  prism  base  up  or  down,  or  in  or  out  before  either  eye.  Instru- 
ments made  to  test  the  equilibrium  of  the  ocular  muscles  depend  for 
their  usefulness  on  one  of  these  methods  and  are  called  phorometers,  those 
of  Stevens  and  Wilson  being  most  commonly  used. 


Figure  2070.    Stevens'  Phorometer. 

Maddox'  Test  for  Heterophoria,  as  illustrated  in  figure  2069,  consists  of 
a  hard  rubber  disc  mounted  in  a  metal  rim  of  trial  frame  size.  The  center 
of  the  disc  contains  a  short  section  of  a  small  glass  rod  which  is  used  in 
connection  with  a  small  single  flame.  This  causes  an  apparent  elongation 
of  the  flame  into  a  thin  line  of  light  quite  different  from  the  flame  itself  as 
seen  at  the  same  time. 

Stevens'  Phorometer,  as  set  forth  in  figure  2070,  contains  two  cells,  in 
each  of  which  rotates  a  disc,  each  disc  carrying  a  prism  of  5°.  Each  disc 
is  furnished  with  a  border  of  teeth  or  cogs.  A  small  gear  wheel  placed  be- 


DETERMINATION  OF    LIGHT  SENSE. 


847 


tween  the  two  discs  communicates  movements  from  one  disc  to  the  other. 
Around  the  outer  part  of  the  border  of  each  cell  is  a  narrow  band  on  which 
is  marked  a  scale  of  degrees  increasing  from  the  center  each  way  from  o° 
to  8°,  the  figures  representing  the  refracting  angle  of  the  prism,  the 
method  of  notation  now  commonly  used. 


Figure  2071.    Wilson's  Photometer. 

The  Wilson  Phorometer,  as  pictured  in  figure  2071,  is  a  combination  of 
the  various  methods  for  examining  the  equilibrium  of  the  ocular  muscles. 
With  it  hyperphoria  in  its  various  forms,  such  as  abduction  and  adduction, 
sursumduction,  deorsumduction,  and  various  other  inefficiencies  may  be  de- 
termined. All  the  tests  for  equilibrium  can  be  made  in  ordinary  cases 
without  the  use  of  any  additional  apparatus.  It  combines  the  Maddox 
tests,  the  method  of  Von  Graefe,  the  principles  involved  in  the  Stevens 
phorometer,  as  well  as  other  important  features.  Its  mechanism  is  best 
explained  by  the  illustration. 

Determination  of  Light  Sense. 

Differing  intensities  of  light  or  the  degree  of  light  perception  may  be 
determined  by  the  use  of  instruments,  the  most  common  of  which  are 
called  photometers. 

Foerster's  Photometer,  as  portrayed  in  figure  2072,  consists  of  a  box 
about  6  by  9  by  12  inches,  painted  black  on  the  inside.  It  is  supplied 
with  a  door  at  each  end,  both  of  which  are  closed  when  in  use.  The  peep- 
holes for  the  eyes  to  be  tested  are  each  supplied  with  curtains  that  may  be 
used  to  shut  off  either  eye,  that  one  may  be  tested  at  a  time.  A  small  win- 
dow is  arranged  that  admits  the  light  from  a  candle  placed  in  a  cylindrical 
receptacle  outside  of  the  chamber.  The  size  of  the  window,  which  can  be 


848 


OPHTHALMIC  SURGERY. 


changed  at  will,  is  the  measure  of  the  amount  of  light  entering  the  box. 
By  means  of  certain  marks  and  characters,  the  sense  of  stimulation  of  the 
retina  may  be  determined. 


Figure  2072.    Foerster's  Photometer. 


Measuring  Field  of  Vision. 

The  field  of  vision  and  its  limitations  may  be  measured  by  a  perimeter. 
While  these  vary  in  detail,  they  usually  consist  of  a  band  curved  to  the  arc 
of  a  circle,  not  less  than  90°  nor  more  than  180°  in  extent.  Its  radius 


0000 


Figure  2073.    Foerster's  Perimeter. 


Figure  2074.     Schweigger's  Perimeter. 


should  be  about  12  inches,  and  the  eye  to  be  examined  should  be  in  the 
center  of  the  circle. 


MEASUREMENT    OF    ACCOMMODATION.  849 

Foerster's  Perimeter,  as  shown  in  figure  2073,  consists  of  a  small  tripod, 
one  leg  of  which  is  elongated  and  curved  to  the  arc  of  a  circle.  Its  upper 
end  is  arranged  to  contain  a  shaft,  upon  the  inner  end  of  which  a  hard  rub- 
ber arc  is  mounted  in  such  a  manner  that  it  may  be  revolved  at  will.  The 
outer  border  of  the  arc  is  graduated  in  degrees,  all  of  which  are  plainly 
marked. 

A  stationary  scale  mounted  upon  the  upright  arm  is  graduated  to  cor- 
respond to  the  divisions  of  the  arc.  By  means  of  this,  the  position  of  the 
object  painted  upon  the  arc  and  the  meridian  of  the  arc  itself  may  be 
pricked  upon  the  chart.  An  adjustable  chin-rest  sliding  in  an  upright  post 
is  attached  to  the  curved  leg  of  a  tripod.  A  handle  is  provided  by  which 
color  discs  may  be  carried  and  the  limits  of  the  field  of  vision  determined. 

Schweigger's  Perimeter,  as  traced  in  figure  2074,  differs  from  the  pat- 
tern of  Foerster  in  being  less  elaborate  in  its  construction.  The  stationary 
disc  and  paper  dial  are  replaced  with  a  plain  pointer  or  marker  by  which 
the  meridian  of  the  arc  may  be  noted. 

Measurement  of  Accommodation. 

This  may  be  measured  by  means  of  suitable  cards  on  which  reading 
matter  is  printed  in  different  sizes  or  fonts  of  type.  These  may  be  pro- 
cured in  various  series,  those  of  Snellen  and  Jaeger  being  generally  pre- 
ferred. 

Measurement  and  Correction  of  Errors  of  Refraction. 

Ordinary  errors  of  refraction  may  be  determined  by  a  series  of  lenses,  a 
set  of  which  is  called  a  trial  case.  Errors  may  be  corrected  by  the  use  of 
spectacles,  the  proper  adjustment  of  which  may  be  determined  by  the  use 
of  trial  frames. 

Astigmatism  will  require  the  use  of  special  dials  and  charts,  usually 
aided  by  the  ophthalmometer,  astigmometer  or  similar  instrument. 

Trial  Sets. 

These  may  be  secured  with  any  desired  number  or  combination  of 
lenses.  The  manufacture  of  trial  lenses  is  comparatively  a  new  industry  in 
this  country.  Although  lacking  long  experience,  our  manufacturers  have 
already  attained  a  high  degree  of  efficiency ;  in  fact,  there  are  several  mak- 
ers of  trial  lenses  in  the  United  States  to-day  whose  wares  are  not  excelled 
by  any  of  the  old  world  opticians.  It  is  not  many  years  since  the  specialist, 
when  purchasing  a  first-class  set,  was  obliged  to  confine  himself  to  the  pat- 
tern of  Nachet  or  some  other  of  foreign  make.  That  this  sentiment  has  been 
overcome  within  a  few  years  is  greatly  to  the  credit  of  American  ingenu- 
ity, coupled  with  a  desire  to  produce  spectacles  and  lenses  equal  to,  if  not 
better  than,  those  of  any  other  country.  As  the  cost  of  a  trial  set  when 
purchased  from  a  reliable  maker  is  determined  by  the  number  of  lenses 
and  the  character  of  their  mounting,  it  is  evident  that  they  may  be  ob- 
tained in  combinations  to  suit  the  price  that  the  purchaser  is  prepared  to 
pay.  We  will,  therefore,  confine  our  illustrations  to  a  single  case,  which 
may  be  purchased  at  a  fair  price,  and  in  which  everything  is  provided  that 
is  really  necessary. 

The  Complete  Set  of  Trial  Lenses,  illustrated  in  figure  2076,  contains 
the  following  lenses  and  accessories  • 

32  Pairs  each — and -{-spherical  lenses  from  .  12  D  to  20  D. 

20  Pairs  each — and-f-cylindrical  lenses  from  .12  D  to  2.  D. 

10  Prisms  from  y2  °  to  10°. 

54 


850 


OPHTHALMIC  SURGERY. 


6  Piano  smoke  lenses,  shades  i  to  6. 

i  Piano  red,  i  piano  blue,  i  chromatic  test. 

i  Maddox's  double  prism,  i  muscle  test. 

i  Pin-hole  disc,  2  stenoptic  discs,  i  solid  disc. 

i  Solid  opaque  disc,  2  half  opaque  discs. 


Figure  2076. 

i  Graduated  trial  frame, 
i  Plain  trial  frame, 
i  Rod  muscle  test, 
i  Prism  muscle  test, 
i  Chromatic  test. 


Complete  Set  of  Trial  Lenses. 


Trial  Frames. 


These  consist  of  mechanism  in  spectacle  form,  each  part  adjustable, 
the  whole  employed  to  accurately  fit  a  suitable  frame  to  the  face.     They 


Figure  2077.    Oculist's  Trial  Frame. 


MEASUREMENT    OF    ACCOMMODATION. 


851 


may  be  in  full  circle  or  half  open  frame  and  with  or  without  graduations  for 
showing  the  angle  of  obliquity  in  cases  of  astigmatism. 

The  Oculist's  Trial  Frame,  exhibited  by  figure  2077,  will  register  all 
the  measurements  required  to  accurately  fit  a  pair  of  spectacles.  A  right 
and  a  left  hand  screw  carry  the  compound  cells  to  the  proper  pupillary  dis- 
tance. The  nose-piece  is  provided  with  both  vertical  and  horizontal  mo- 
tion to  allow  any  height  or  position.  Both  the  temple  and  pupillary  dis- 
tances may  be  plainly  marked  as  well  as  the  position  of  the  crest  of  the 
nose-piece. 

Astigmatism,  as  before  stated,  may  be  determined  and  measured  by 
various  forms  of  instruments.  Lack  of  space  will  prevent  our  illustrating 
more  than  a  limited  number  of  these. 

Test  Types. 

The  Astigmatic  Dials,  shown  by  figures  2078,  2079  an<^  2080,  are  three 
of  the  forms  of  charts  employed  for  determining  the  existence  of  astigma- 
tism. They  may  be  obtained  from  dealers  in  surgical  or  optical  appliances. 


Figure  2078.    Astigmatic  Dial  on 
Circular  Card. 


Figure  2079.    Astigmatic  Clock 
Dial. 

Ophthalmometers. 


Figure  2080.    Astigmatic  Dial  on 
Circular  Card. 


These  practically  consist  of  adjustable  refracting  surfaces  or  targets  so 
gauged  that  the  corneal  image  may  be  accurately  measured  by  a  focusing 
apparatus  or  eye-piece  placed  between  the  eye  of  the  patient  and  that  of 
the  observer. 

The  Javal-Schiotz  Ophthalmometer,  as  pictured  in  figure  2081,  is  one  of 
the  many  forms  in  which  this  instrument  may  be  obtained.  This  is  due  to 
the  fact  that  the  original  model  has  been  changed  and  modified  not  only  by 
ist  inventors,  but  by  oculists  and  manufacturers.  It  consists  of  a  telescope 
supported  by  an  upright  and  mounted  upon  a  tripod ;  a  large  graduated 
steel  disc  or  dial  attached  to  the  telescope;  a  graduated  arc;  two  "mires" 
designated  as  "the  steps"  and  "the  parallelogram,"  both  of  which  are 
attached  to  the  arc ;  a  metal  base  with  support  for  the  head  by  means  of  a 
chin-rest,  and  a  gas  or  electric  light  apparatus  for  illumination. 

Hardy's  Ophthalmometer,  as  illustrated  in  figure  2082,  consists  of  a 
telescope  to  which  are  attached  arcs  carrying  sliding  targets  called 
"mires. " 

This  instrument  gives  the  oculist  positive  information  as  to  the  amount 
and  axis  of  corneal  astigmatism  by  an  objective  test  uninfluenced  by  the 
patient. 

The  principle  on  which  it  is  based  is  the  measurement  of  the  corneal 
curves  by  means  of  reflected  images  viewed  through  a  telescope. 


I:  !.!  V  SCI  r  I 


852 


OPHTHALMIC  SURGERY. 


When  the  cornea  is  viewed  through  this  instrument,  it  is  seen  doubled, 
the  reflection  of  the  mires  upon  the  cornea  also  being  doubled.  The  re- 
flected images  of  the  mires  being  farther  apart  on  a  cornea  of  longer  curva- 


Figure  2081.    The  Javal-Schiotz  Ophthalmometer. 

ture,  or  nearer  together  on  one  of  shorter  curvature,  the  amount  of  differ- 
ence between  the  curvature  of  any  two  meridians  of  the  cornea ;  that  is,  the 
astigmatism,  can  be  determined  by  the  relative  position  of  the  images. 

The  axis  of  the  astigmatism  is  determined  by  the  position  of  the  merid- 
ians in  which  the  black  lines  bisecting  the  mires  are  continuous. 


Figure  2082.    Hardy's  Ophthalmometer. 

Hotz'  Astigmometer,  as  outlined  in  figure  2083,  consists  of  a  square 
plate  of  hard  rubber,  to  which  is  attached  a  rotating  disc  7  centimeters  in 
diameter.  The  disc  is  provided  with  two  small  circular  apertures  with 
their  centers  in  the  same  radius,  and  on  its  periphery  in  the  same  radius 
a  small  arrow-point  or  marker.  The  edges  of  the  apertures  are  made  very 


JJO 


PROTECTIVES. 


853 


thin  and  sharp  by  beveling  the  metal  on  the  posterior  surface,  while  the 
front  of  the  disc  is  even  and  smooth.  A  piece  of  ground  glass  or  mica  is 
placed  over  the  opening  at  the  posterior  surface  of  the  disc  in  order  to 
diffuse  the  transmitted  light  evenly  over  the  apertures  and  to  bring  out 


Figure  2083.    Hotz'  Astigmometer. 

their  contours  sharply.  A  graduated  scale  from  o  to  180  surrounds  the 
disc  at  the  distance  reached  by  the  marker  before  mentioned.  To  the  as- 
tigmatic eye  the  points  of  light  will  appear  drawn  out  or  elongated  in  the 
direction  of  one  of  the  principal  meridians.  By  turning  the  disc,  the  exact 
angle  of  astigmatism  may  be  determined. 

Protectives. 

Means  for  protecting  the  eye  from  exposure  to  light  and  air  may  be  ob- 
tained in  the  form  of  shades,  shields,  goggles,  glasses,  etc. 


Figure  2084.    Single  Eye  Shade. 


Figure  2085.    Double  Eye  Shade. 


Single  and  Double  Eye  Shades,  as  represented  in  figures  2084  and  2085, 
may  be  obtained  of  various  materials,  those  slightly  stiffened  with  leather 
or  cardboard  and  covered  with  dark  silk  being  usually  preferred.  They 
are  recommended  in  many  diseases,  particularly  conjunctivitis. 


CHAPTER  XXXI. 


OBSTETRICAL    SURGERY. 

The  instruments  and  appliances  employed  in  the  delivery  of  the  embryo 
or  fetus  and  the  first  care  of  new-born  infants,  may  be  classified  as  those  for 
management  of  normal  labor,  artificial  abortion,  relieving-  asphyxia  in  the 
infant,  painful  or  imperfect  nursing,  premature  infants,  removal  of  retained 
placenta,  measurements  of  pelvis,  symphyseotomy,  Cesarean  section, 
instrumental  delivery,  appliances  for  hip  and  breech  presentations,  and 
embryotomy. 


MANAGEMENT  OF  NORMAL  LABOR. 

This,  so  far  as  convenience  and  aseptic  conduct  are  concerned,  will 
require : 

Permanent  rubber  sheet  for  protection  of  mattress. 

Permanent  bed  sheet  for  use  of  patient  after  operation. 

Second  rubber  sheet  for  use  of  patient  after  operation.  (This  should 
rest  over  the  permanent  bed  sheet  before  mentioned.) 

Folded  sheet  to  rest  directly  under  patient  for  absorbing  discharges. 

Obstetrical  pad,  figure  200. 

Bed-pan,  figures  166  to  170. 

Irrigating  fountain  syringe,  figure  693. 

Absorbent  cotton,  figure  729. 

Absorbent  gauze,  figure  794. 

Fluid  extract  of  ergot. 

Soft  rubber  catheter,  figure  1262. 

Anesthetics,  figures  329  to  351. 

Hypodermic  syringe  with  compressed  tablets,  figures  360  to  370. 

Silkworm  gut  or  other  ligature  material,  figures  708  to  734. 

Scissors,  figures  631  to  635. 

Rubber  Bed  Blankets. 


Figure  2086.    Rubber  Bed  Blanket. 


Plain  rubber  sheeting  is  usually  selected  for  this  purpose  and  answers 
every  requirement  for  permanent  protection.  The  obstetrician  may,  how- 
ever, provide  himself  with  a  special  blanket  that  will  form  a  portion  of  his 
obstetrical  outfit. 

854 


MANAGEMENT  OF  NORMAL  LABOR. 


855 


Rubber  Bed  Blankets,  as  set  forth  in  figure  2086,  are  required  for  so 
many  classes  of  cases  that  it  is  thought  best  to  include  a  description  of  them 
in  this  chapter.  While  ordinary  sheeting  will  answer  a  fair  purpose, 
blankets  provided  with  eyelets  and  turned  edges  will  be  found  more  satis- 
factory. Usually,  they  are  manufactured  from  a  good  quality  of  black  rub- 
ber cloth.  The  sizes  generally  found  in  the  market  are  50  inches  in  width, 
and  either  36  or  72  inches  in  length. 

Scissors. 

Scissors  for  obstetrical  use  need  not  vary  from  the  patterns  ordinarily 
found  in  the  market.  Those  with  either  straight  or  curved  edges  may  be 
employed. 


Figure  2087.    Umbilical  Cord  Scissors. 

The  Umbilical  Cord  Scissors,  displayed  in  figure  2087,  are  constructed 
with  short,  wide  blades,  the  inner  or  cutting  surfaces  of  which  present  a  con- 
cave face  each  to  the  other.  They  may  be  advantageously  employed  for 
this  purpose,  because  the  bite,  if  not  parallel,  is  so  arranged  that  in  the 
closing  of  the  blades,  the  cord  is  not  likely  to  be  forced  from  between 
them. 


Figure  2088.     Kellogg's  Elastic  Funis  Ring  Applicator. 

Kellogg's  Elastic  Funis  Ring  Applicator,  as  exhibited  in  figure  2088, 
consists  of  a  system  of  four  short  dilating  blades  arranged  for  stretching  a 
rubber  band,  passing  it  over  the  stump  of  an  umbilical  cord,  and,  when 
properly  adjusted,  releasing  the  ring.  The  blades,  when  closed  together,  are 
in  conical  form,  and  so  adjusted  that  their  tips  may  be  expanded  as  desired. 
The  controlling  mechanism  is  that  of  an  ordinary  forceps  with  handles ;  one, 
the  lower,  being  attached  to  a  fixed  ring  to  which  the  blades  are  hinged ; 
the  other  terminating  in  a  hinged  separator,  by  the  action  of  which  (the 
blades  are  caused  to  diverge  from  a  common  center.  The  rings  employed 
are  small,  heavy  rubber  bands.  One  of  these  may  be  fixed  on  the  tips  of 
the  four  prongs  of  the  instrument  and  the  blades  dilated  and  slipped  over 


856  OBSTETRICAL  SURGERY. 

the  pedicle,  where  the  band  may  be  released  and  the  instrument  withdrawn. 
It  is  claimed  that  this  furnishes  a  safe  and  sterile  ligature;  that  it  is  more 
quickly  and  easily  applied ;  that  the  pressure  is  firm  and  positive,  and  that 
it  avoids  the  dangers  of  hemorrhage  and  infection. 


ARTIFICIAL   ABORTION. 

The  instruments  usually  required  for  the  induction  of  premature  labor 
may  consist  of : 

Dilator  for  enlarging  the  cervix,  figures  1036  to  1052. 

Curette  for  breaking  up  and  loosening  ovum,  figures  1078  to  1085. 

Catheter  for  withdrawing  urine,  figures  1053  to  1055. 

Irrigating  tube  for  washing  out  uterus,  figures  1183  to  1186. 

Syringe  for  emptying  bowels. 

Speculum  for  exposing  parts,  figures  988  to  1008. 

Tenaculum  forceps  for  drawing  down  uterus,  figures  1021  to  1024. 

Packing  forceps  for  inserting  gauze  for  drainage,  figures  1086  to  1089. 

Dilators. 

Dilators  for  this  purpose  may  be  made  from  metal  with  diverging  blades, 
or  may  consist  of  rubber  bulbs,  to  be  expanded  by  the  forced  introduction 
of  water.  As  the  latter  are  less  likely  to  injure  the  mucous  surfaces  in  cases 
of  extreme  dilatation,  and  as  they  may  be  procured  in  large  sizes,  they  are 
usually  preferred.  To  avoid  the  dangers  of  infection,  none  but  sterilized 
water  in  a  sterilized  bag  should  be  employed.  As  the  ordinary  forms  of 
dilators,  including  Barnes'  bags,  which  are  most  frequently  employed  for 
this  purpose,  are  fully  described  by  figures  1036  to  1052,  we  will  include 
only  one  pattern  which  has  a  particular  application  to  this  class  of  cases. 


Figure  2089.    Maclean's  Uterine  Dilator. 


Maclean's  Uterine  Dilator,  as  illustrated  in  figure  2089,  comprises  two 
Barnes'  bags  cemented  together  upon  their  flat  sides.  As  in  the  usual  pat- 
terns, each  is  provided  with  a  separate  tube  for  dilatation.  After  introduc- 
tion, one  of  the  bags  may  be  injected  and  dilated.  If  sufficient  distention  is 
not  produced,  the  second  may  be  dilated  in  a  similar  manner. 

Ovum  Forceps. 

These  do  not  differ  materially  from  some  of  the  larger  patterns  of  pla- 
centa forceps,  a  full  description  of  which  may  be  found  in  connection  with 
figures  2094  to  2096. 


ASPHYXIA  IN   THE  NEW-BORN  INFANT 


857 


Lenneker's  Ovum  Forceps,  as  depicted  in  figure  2090,  have  strong 
handles  and  blades,  the  latter  terminating  in  large  fenestrated  jaws. 
The  openings  in  the  latter  are  oval  with  flaring  serrated  sides,  that  afford  a 


Figure  2090.    Lenneker's  Ovum  Forceps. 

firm  grasping  surface  for  any  soft  tissues  that  may  be  included  in  the  bite 
of  the  instrument.  As  usually  manufactured,  this  instrument  is  9^ 
inches  in  length. 


ASPHYXIA  IN  THE  NEW-BORN  INFANT. 

This  may  often  be  overcome  by  artificial  respiration.  In  addition  to 
position  and  the  regularly-prescribed  movements  and  manipulations,  'it 
may  require  the  use  of  an  exhaust  and  forcing  bulb,  by  which  any  obstruct- 
ing mucus  may  be  removed  by  suction,  and,  by  the  same  appliance,  air 
forced  into  the  lungs. 


Figure  2091.    Ribemont's-Dessaingues'  Insufflator  and  Suction  Syringe. 

Ribemont's-Dessaingues'  Insufflator  and  Suction  Syringe,  as  depicted  in 
figure  2091,  combines  a  bulb  of  the  Politzer  type  attached  to  a  laryngeal 
tube.  The  former  is  usually  of  8  or  lo-ounce  capacity,  while  the  latter  is 
made  from  hard  rubber  and  curved  to  pass  into  the  deeper  portions  of  the 
trachea.  Several  small  lateral  perforations  and  one  at  the  end  are  em- 
ployed as  openings,  through  which  any  contacted  mucus  may  be  drawn  by 
the  exhaust  force  of  the  bulb.  The  joint  connecting  the  latter  with  the 
tube  should  be  of  a  plain  slip-over  pattern,  that  the  bulb  may  be  quickly 
attached  and  speedily  emptied  of  any  contained  fluid. 


PAINFUL  OR  IMPERFECT  NURSING. 

If,  from  diseases  of  the  nipple  or  other  causes,  nursing  is  painful  to  the 
mother  or  imperfectly  performed  by  the  infant,  resort  may  be  had  to  nip- 
ple-shields. These  consist  of  small  cups  fitting  closely  around  the  nipple, 
to  which  small,  perforated,  soft  rubber  nipples  may  be  attached,  either 
directly  to  the  cup,  or  a  rubber  hose  may  be  employed  to  lengthen  the  dis- 


858 


OBSTETRICAL  SURGERY. 


tance  between  the  cup  and  the  bulb.  Where  the  assistance  of  the  mother 
is  required,  or  in  cases  where  auto-aspiration  of  the  breast  contents  is  neces- 
sary, a  cup  with  a  double  tube  may  be  used. 


Figure  2092.    Qouble-Tube  Nipple-Shield. 

The  Double-Tube  Nipple-Shield,  exhibited  in  figure  2092,  consists  of  a 
small  glass  bowl-shaped  cup,  provided  near  its  apex  with  two  lateral  open- 
ings. To  one,  by  means  of  a  rubber  hose,  a  small  nursing  nipple  is  attached. 
The  second,  a  longer  piece  of  hose,  terminates  in  a  mouth-piece,  that  may 
be  used  by  the  mother  or  nurse. 


PREMATURE  INFANTS. 

Premature  infants  possessing  slight  powers  of  resisting  atmospheric  and 
other  changes,  require  artificial  means  for  the  maintenance  of  a  uniform 
and  adequate  body  heat.  This  may  be  secured  by  a  properly-arranged 
incubator. 


Figure  2093.    Automatic  Infant  Incubator. 

The  Infant  Incubator,  exhibited  in  figure  2093,  consists  of  an  oblong 
chamber  provided  with  means  for  heating  and  ventilation,  by  which  a  uni- 
form temperature  may  be  permanently  maintained. 

The  chamber  consists  of  a  box  30  inches  in  length,  24  inches  in  height 
and  16  inches  in  width,  resting  on  a  platform  n  inches  longer  than  the  box. 
This  latter  feature  provides  a  base  for  the  attachment  of  the  heating  appa- 
ratus, thus  keeping  the  latter  outside  of  the  chamber  and  ensuring  greater 
safety  to  the  infant.  The  steam  boiler  consists  of  a  copper  retort  of  about 
^-gallon  capacity,  provided  at  its  top  with  a  strong  screw  clamp  and  an 
L-shaped  steam  discharge  pipe,  by  which  connection  is  made  with  coiled 


REMOVAL  OF  RETAINED  PLACENTA.  859 

pipes  within  the  chamber.  The  retort  is  held  in  place  by  a  double  ring- 
stand,  heat  being  applied  by  a  Bunsen  burner,  an  alcohol  or  an  oil  stove. 
A  small  copper  tank  is  also  placed  on  the  base,  into  which  condensed  steam 
is  conducted.  A  heavy  railing  surrounds  these  accessories,  which  not  only 
protects  them  from  injury,  but  serves  as  a  guard  to  prevent  the  clothing  of 
the  assistants  from  becoming  ignited  in  the  flame.  The  lower  portion  of 
the  chamber  contains  a  series  of  lead  coils  placed  within  a  galvanized  iron 
tray.  By  filling  the  latter  with  sand,  a  uniform  radiation  of  heat  may  be 
secured.  Six  circular  openings,  three  above  and  three  below  upon  each 
side,  all  covered  with  hinged  metal  caps,  serve  to  supply  the  necessary  ven- 
tilation. A  wire  gauze  cradle,  padded  with  soft  material,  is  supended  within 
the  chamber  in  such  a  manner  as  to  receive  the  uniform  heat  generated  by 
the  steam  coils.  Its  inside  measurements  are  21  inches  in  length,  10  inches 
in  width,  and  10  inches  in  depth.  Four  spring  clips  serve  to  hold  the 
chamber  in  place  and  furnish  an  easy  means  for  its  removal.  An  electro- 
thermostat  is  located  within  the  chamber.  This  consists  of  a  long  arm,  man- 
ufactured by  riveting  together  two  thin  plates,  one  of  rubber  and  one  of 
metal.  By  an  accurate  adjustment  this  may  be  regulated  so  that  a  varia- 
tion from  a  given  temperature  will  furnish  the  necessary  connection  with  a 
small  electric  bell.  This  bell  will  ring  until  an  assistant  corrects  the  tem- 
perature. It  may  be  set  at  95°  and  100°,  so  that  when  the  temperature 
reaches  a  point  below  or  above  these  figures,  either  warmer  or  colder,  the 
bell  will  commence  ringing.  A  sliding  glass  door  furnishes  a  cover  that 
may  be  readily  removed. 


REMOVAL  OF  RETAINED  PLACENTA. 

The  placenta,  when  not  spontaneously  expelled,  may  require  dislodgment 
by  artificial  means.  While  the  use  of  special  instruments  is  seldom  advised, 
the  fact  remains  that  there  is  a  large  commercial  demand  for  placental  ex- 
tractors. Without,  therefore,  assuming  to  advise  the  use  of  instruments  for 
this  purpose,  the  above  conditions  would  seem  to  warrant  the  introduction 
and  description  of  such  patterns  as  are  deemed  most  valuable.  They  com- 
prise curettes,  scoops,  screws,  hooks ;  in  fact,  the  whole  range  of  surgical 
mechanics  seems  to  have  been  invaded  with  a  view  to  producing  something 
new  for  this  operation. 


Figure  2094.    Budd's  Placenta  Forceps. 


Budd's  Placenta  Forceps,  as  shown  in  figure  2094,  are  of  heavy  construc- 
tion, about  12  inches  in  length,  with  a  pivot  near  the  junction  of  the  first 
and  second  thirds.  The  blades  are  long,  slightly  curved  on  the  flat,  ter- 
minating in  bulbous  fenestrated  jaws  provided  with  transverse  serrations. 
The  inner  surfaces,  or  those  surrounding  the  fenestrae,  are  bowl-shaped, 
thus  securing  a  good  grasping  surface. 

Grosvenor's  Placenta  Forceps,  as  illustrated  in  figure  2095,  are  about  9 
inches  in  length,  of  light  and  delicate  construction,  the  blades  terminating 


860 


OBSTETRICAL  SURGERY. 


in  large  ovoid  fenestrae.  The  metallic  loops  forming  the  borders  of  the  fenes- 
trae  are  thin,  with  medium  sharp  edges,  that  under  slight  pressure  become 
embedded  in  the  soft  mass,  thus  furnishing  a  firm  grasp. 


Figure  2095.    Grosvenor's  Placenta  Forceps. 


Longear's  Placenta  Forceps,  as  depicted  in  figure  2096,  are  about  10 
inches  in  length  with  handles  slightly  curved  down  and  blades  curved  up  on 
the  flat.  The  jaws  are  long  and  slender,  the  inner  borders  being  provided 


Figure  2096.    Longear's  Placenta  Forceps. 


with  wide  central  grooves  extending  throughout  the  length  of  the  jaw. 
The  outer  margins  #re  transversely  serrated. 

Unlike  those  previously  described,  this  instrument  is  constructed  with  a 
catch  handle. 


Figure  2097.    Mundfi's  Curette. 


Munde's  Curette,  as  depicted  in  figure  2097,  is  a  long  slender  tapering 
shaft  terminating  in  a  slender  loop-shaped  fenestra.  The  border  of  the 
fenestra  is  rounded  upon  the  outer,  and  flattened  upon  the  inner  surface,  so 
that  two  forms  of  contact  edges  are  available  for  use.  As  the  instrument 
is  flexible,  it  may  be  curved  to  any  desired  form.  As  generally  manufac- 
tured, the  shaft,  exclusive  of  the  handle,  is  about  10  inches  in  length. 


Figure  2098.    Lenneker's  Placenta  Curette. 

Lenneker's  Placenta  Curette,  as  set  forth  in  figure  2098,  consists  of  a 
strong  rigid  shank  and  handle,  the  former  in  bayonet  shape.  At  its  distal 
end  the  shaft  is  formed  into  a  large  oval  loop  with  semi-cutting  edges, 
curved  on  the  flat  at  an  angle  of  45°.  The  upper  or  outer  borders  of  the 
loop  present  smooth  and  well-rounded  surfaces,  so  that  injury  to  the  uterine 
wall  would  seem  impossible.  The  peculiar  shape  of  the  instrument  fits  it 
for  detaching  all  retained  placental  fragments  and  pulling  or  scraping  them 
out  of  the  cavity. 

McNaughton's  Placenta  Curette  consists  of  a  shaft  in  sigmoid  shape, 
each  end  of  which  is  formed  into  an  oval  loop.  One  of  these  is  fa  of  an  inch, 


MEASUREMENTS    OF    PELVIS. 


861 


and  the  other  1^3  inches  in  transverse  external  diameter.  As  the  entire  in- 
strument is  manufactured  from  a  single  piece  of  steel  wire  it  presents  no 
sharp  edges  or  angles.  It  is  well  exhibited  in  figure  2099. 


Figure  2099.    McNaughton's  Placenta  Curette. 


MEASUREMENTS  OF  PELVIS. 

The  presence  of  pelvic  deformity  may  be  determined  by  measurements 
with  a  form  of  caliper  that,  when  used  for  this  purpose,  is  usually  called  a 
pelvimeter.  This  generally  consists  of  two  arms  so  curved  and  shaped  as 
to  show  on  a  graduated  scale  the  distance  between  the  tips  at  any  time. 


Figure  2100.     Baudelocque's 
Pelvimeter. 


Figure  2101.    Martin's  Pelvimeter. 


Baudelocque's  Pelvimeter,  as  described  in  figure  2100,  consists  of  two 
semi-circular  arms,  each  of  which  at  its  proximal  end  extends  in  a  straight 
section  laterally  projected  in  the  form  of  a  handle,  the  extremities  being 
hinged  together.  Usually  they  represent  a  circle  about  9  inches  in  diameter, 
with  a  straight  or  handle  portion  equal  in  length  to  the  radius  of  the  circle  or 
4^  inches. 

A  quadrant  attached  at  a  bend  in  one  arm,  and  extending  through  the  slot 
in  the  opposite  one,  is  graduated  and  serves  as  a  scale  to  mark  in  centimeters 
the  distance  between  the  tips.  A  set  screw  is  provided,  by  which  fixation 
may  be  secured  at  any  point. 

Martin's  Pelvimeter,  as  exhibited  in  figure  2101,  comprises  two  hinged 
shafts  about  13  inches  in  length,  their  outer  ends  curved  inward  on  the  edge 
and  provided  with  bulbous  tips.  A  graduated  cross-bar  in  quadrant  form 
located  about  three  inches  from  the  hinge,  and  extending  from  one  blade 
through  a  slot  in  the  other  shows  by  a  marker  the  amount  of  expansion 
secured. 


862  OBSTETRICAL  SURGERY. 

Collin's  Pelvimeter,  as  pictured  in  figure  2102,  comprises  two  flattened 
arms  with  bulbous  points,  hinged  at  their  proximal  ends.  The  lower  blade 
extends  in  the  form  of  a  circular  plate,  upon  the  outer  margin  of  which  the 
graduated  scale  is  carefully  traced.  To  the  upper  blade,  also  projecting 


Figure  2102.     Collin's  Pelvimeter. 

backward,  a  short  arm  or  marker  is  attached  in  such  a  position  that  diver- 
gence of  the  blade-tips  causes  this  to  swing  around  the  graduated  semi-circle, 
thus  indicating  at  all  times  the  distance  between  the  blade  tips.  As  the 
blades  cross,  this  instrument  may  be  used  to  determine  dimensions  of  cavities, 
the  scale  being  so  designed  as  to  indicate  these  also. 


SYMPHYSEOTOMY. 

In  cases  of  pelvic  stenosis  this  is  sometimes  employed  in  preference  to 
the  older  operation  of  Cesarean  section.  The  necessary  instruments  do 
not  differ  from  those  included  in  the  minor  operating  set  described  on  pages 
270  to  275,  with  the  exception  that  a  special  knife  for  separating  the  inter- 
pubic  cartilages  is  usually  advised. 


Figure  2103.    Galbiati's  Modified  Sickle-Shaped  Knife. 

Galbiati's  Modified  Sickle-Shaped  Knife,  as  shown  in  figure  2103,  con- 
sists of  a  strong  handle  and  blade,  the  latter,  heavy,  probe-pointed  and  re- 
curved on  the  edge  in  sickle  shape.  The  cutting  portion  of  the  blade  is 
usually  about  3  inches  in  length,  the  full  length  of  the  instrument  about  7 
inches,  while  the  plane  of  the  tip  occupies  a  position  about  i  ^  inches  below 
that  of  the  straight  portion  of  the  cutting  edge. 


CESAREAN  SECTION. 

This  operation  requires  about  the  same  list  of  instruments  as  for  any 
other  laparotomy. 


INSTRUMENTAL    DEL1VERV.  863 


INSTRUMENTAL  DELIVERY. 

Obstetrical  forceps  are  employed  as  a  means  to  secure  traction  in  cases 
where  the  natural  expulsive  forces  prove  insufficient  to  overcome  the  resist- 
ance offered  to  the  passing  fetus.  Their  essential  features  consist  .of  blades 
so  shaped  as  to  secure  firm,  yet  non-injurious,  contact  with  the  fetal  head, 
parts  that  are  easily  separable,  handles  that  afford  a  firm  grip  and  a  con- 
struction that  admits  of  surgical  sterilization.  Like  specula  and  pessaries, 
they  are  recommended  in  many  forms  and  sizes,  varying  from  the  seeming 
formidable  axis-traction  instrument  of  Tarnier  to  the  almost  worthless 
"pocket"  patterns  advised  by  instrument  makers.  With  the  exception  of  a 
majority  of  the  short  forceps,  all  may  be  considered  as  good  and  reliable 
patterns,  success  and  safety  depending  almost  entirely  on  the  conditions 
encountered  and  the  skill  of  the  operator.  As  now  designed,  they  vary  but 
little  in  essential  features,  nearly  all  being  manufactured  according  to  gen- 
erally accepted  plans.  As  originally  constructed,  the  blades  had  only 
a  cephalic  curve,  so  that  when  viewed  edgewise,  they  were  straight  in  profile. 
Now,  in  addition  to  the  cranial,  they  are  manufactured  with  a  pelvic  curve 
that  more  closely  conforms  to  the  shape  of  the  birth-canal. 

All  should  be  constructed  of  steel,  well  tempered,  elastic,  but  never  flex- 
ible. In  this  connection,  it  would  seem  advisable  that  on  purchasing,  each 
surgeon  should  protect  himself  and  his  patients  by  carefully  testing 
obstetrical  forceps  to  see  that  they  possess  this  essential  quality.  A  cir- 
cular post  or  other  firm  substance  tightly  grasped  between  the  blades  will 
determine  beyond  reasonable  doubt,  if  considerable  force  be  exercised, 
whether  or  not  such  forceps  can  be  depended  upon  in  actual  service.  All 
should  be  manufactured  with  smooth  surfaces,  free  from  sharp  points  and 
angles,  and  finely  polished  and  nickel-plated. 

Mechanically,  obstetrical  forceps  may  be  divided  into  four  parts :  handle, 
shank,  blade  and  lock.  The  handle  in  nearly  all  patterns  is  much  shorter 
than  the  blade.  This,  as  a  rule,  is  intentional  in  order  to  avoid  giving  the 
operator  too  great  compressing  power.  Formerly,  the  handles  of  many 
straight  patterns  were  serrated,  or  otherwise  roughened,  but,  as  this  method 
of  securing  a  good  grasping  surface  rendered  the  instrument  more  difficult 
to  clean,  deep  grooves  or  finger  indentations  have  been  substituted. 

Not  a  few  patterns  of  handles  are  curved  downward  on  the  flat,  while 
others  are  curved  laterally  on  the  edge,  both  furnishing  good  grasping  sur- 
face. Some  are  provided  with  lateral  projections  or  wings  at  the  inner  por- 
tions of  the  handles  that  serve  as  contact  surfaces  for  the  first  two  fingers, 
thus  assisting  in  securing  a  better  grasp.  The  blades  of  nearly  all  patterns 
are  fenestrated,  not  only  because  they  are  lighter,  but  for  the  reason  that  they 
fit  the  fetal  head  more  closely  and  thus  occupy  less  space.  The  form  of  the 
fenestra  is  that  of  an  elongated  oval,  the  blades  usually  being  wider  at 
their  extremities.  The  cephalic  curve  is  elliptical  in  form,  though  not 
always  the  same  at  the  upper  and  lower  margins. 

When  the  handles  are  closed,  the  blades  are  usually  separated  by  a  space 
varying  from  yz  an  inch  to  i  inch  at  the  tips,  depending  somewhat  on  the 
rigidity  of  the  pattern,  in  order  to  avoid  over-pressure  on  the  base  of  the 
skull.  The  blades  vary  from  6  to  7  inches  in  length,  and  from  2  to  2^ 
inches  in  breadth  at  their  widest  part.  The  distance  between  the  blades  in 
the  widest  portion  of  the  cephalic  curve  varies  from  2^  inches  in  the  Hodge 
and  Davis  patterns  to  3  inches  in  the  Simpson  and  Knox  instruments. 


864  OBSTETRICAL  SURGERY. 

The  length  of  the  fenestrae  varies  from  4  to  5  inches,  the  latter  being  the 
more  common.  The  height  of  the  pelvic  curve  varies  greatly.  Measuring 
from  the  outer  border  of  the  fenestra  from  a  line  representing  the  center 
of  the  long  axis  of  the  opening  to  a  plane  represented  by  the  extreme  lower 
border  of  the  blades,  it  is  from  2  to  3  inches.  This  measurement  of  course 
includes  one-half  of  the  width  of  the  blade  at  its  tip. 

The  locks  are  of  three  varieties,  one  a  plain  pin  surmounted  by  a  large 
button  that  fits  closely  into  a  mortise  or  obliquely -cut  slot  in  the  upper 
blade,  as  in  the  pattern  of  Miller.  Another  consists  of  a  similar  pin  and 
mortise,  but  employs  instead  of  a  button  a  thumb- screw,  by  which  the 
handles  may  be  securely  locked.  This  form  is  exemplified  in  the  pattern 
of  Hodge.  The  third  and  more  common  pattern,  sometimes  called  the 
English  lock,  consists  of  a  mortise  and  tenon,  the  shoulders  of  which  are 
obliquely  inclined,  the  two  fitting  accurately  and  closely  together.  The 
shank  of  each  blade  fits  into  a  corresponding  recess  in  the  other. 

The  length  varies  from  n  to  12  inches  in  the  short,  and  from  15  to  16 
inches  in  the  long  patterns.  While  the  latter  may  be  used  for  all  purposes, 
the  former  can  only  be  employed  after  the  head  of  the  child  has  reached  the 
pelvic  brim.  While  the  majority  are  constructed  with  straight  handles  and 
shanks,  some  are  designed  to  produce  traction  in  a  line  with  the  birth-canal 
before  the  head  reaches  the  pelvic  floor.  This  necessitates  a  forceps  with 
from  a  downward  and  backward  force  may  be  imparted,  which  may  be  se- 
cured by  different  methods.  In  the  forceps  of  Knox  the  shanks  are  in  bay- 
onet form,  the  axis  of  the  blades  being  parallel  to  but  in  a  different  plane 
from  that  of  the  handle.  Others  attach  traction  bars  at  or  near  the  proximal 
border  of  the  fenestrae  with  a  view  of  securing  downward  pressure,  while 
the  Tarnier  forceps  seeks  to  combine  both  of  these  methods  in  a  single  in- 
strument. 

Some  have  set  screws  by  which  the  handles  are  prevented  from  complete 
closure,  thus  avoiding  undue  cranial  pressure.  As  such  patterns  are  diffi- 
cult to  cleanse,  many  operators  prefer  to  insert  a  folded  towel  between  the 
handles. 


Figure  2104.    Hodge's  Forceps. 

Hodge's  Forceps,  as  exhibited  in  figure  2104,  belong  to  that  class 
wherein  a  single  forging  is  made  to  answer  for  each  blade  and  handle.  The 
latter  are  slightly  spread  where  grasped  by  the  hand,  that  they  may 
furnish  a  good  sized  grasp,  while  the  tips  of  the  handles  are  curved  outward 
in  the  form  of  hooks,  thus  affording  a  stronger  grasping  surface.  The  lock 
is  of  the  screw  device,  by  which  the  blades  are  securely  held  together. 
The  shanks  between  the  lock  and  the  blades  rest  one  above  the  other,  thus 
occupying  but  little  space.  The  blades  are  fenestrated,  the  openings  being 
about  i  inch  wide  and  5  inches  long.  The  distance  between  the  blades  is 
about  2^  inches,  and  the  pelvic  curve,  when  measured,  according  to  the 
method  before  described,  is  about  2^  inches.  They  are  about  1 6  inches 
long. 


INSTRUMENTAL    DELIVERY. 


865 


Wallace's  Forceps,  as  represented  in  figure  2105,  differ  essentially  from 
the  pattern  of  Hodge  only  in  the  shape  of  the  blades,  which  possess  a  more 
marked  pelvic  curve  and  wider  fenestrse.  the  latter,  at  their  extreme  part, 


Figure  2105.    Wallace's  Forceps. 


being  i^  inches.     The  height  of  the  pelvic  curve  is  3,  and  the  full  length 
of  the  forceps  15^  inches. 

Miller's  Forceps,  as  portrayed  in  figure  2106,  are  of  heavy  construction 
with  a  lock  of  the  pin  and  button  pattern.  The  handles  are  usually  of 
metal,  cast  hollow,  that  they  may  not  be  of  overweight.  The  blades,  from 


Figure  2106.     Miller's  Forceps. 

the  lock  forward,  spread  outward,  forming  long  slender  fenestrae,  the  latter 
usually   5  ^  inches  in  length  by   i   inch  in  breadth  at  their  widest  part. 
A  narrowing  of  the  handles  near  the  tip  and  lateral  projections  near  the 
lock  furnishes  a  good  grasping  surface.     The  length  is  about  15  inches. 


Figure  2107.    Simpson's  Forceps. 

Simpson's  Forceps,  as  set  forth  in  figure  2107,  have  a  relatively  short 
handle  provided  with  finger  indentations  and  transverse  shoulders,  the  whole 
forming  firm  grasping  surfaces.  This  forceps,  as  recently  constructed,  has 
each  blade  made  from  a  single  piece  of  steel,  the  handles  being  hollowed 
out  by  machinery  to  avoid  overweight.  A  prominent  feature  in  this  pat- 
tern is  the  lateral  divergence  of  the  shanks,  which  commences  at  the  locks 
and  extends  forward  until  the  blade  formation  begins.  This  usually  em- 
braces about  2^  inches  of  the  length  of  the  instrument,  the  inner  breadth 
between  the  parallel  shanks  being  about  i  inch.  The  fenestrae  are  about 
4%  inches  in  length,  narrow  at  their  proximal  border  and  gradually  widen- 
ing until  at  the  tip  they  are  i^  inches  broad.  The  greatest  breadth  of 
the  cephalic  curve  is  3  inches,  while  the  height  of  the  pelvic  curve  to  the 
center  of  the  blade  is  2  inches.  The  length  is  about  13^  inches. 

55 


866 


OBSTETRICAL  SURGERY. 


Elliott's  Forceps,  as  set  forth  in  figure  2108,  vary  in  general  shape  but 
little  from  the  pattern  of  Miller  before  described.  The  handles  are  of  the 
same  general  form,  but  a  trifle  shorter.  The  lock  is  of  the  English  mortise 
and  tenon  design.  A  pin  placed  within  the  proximal  portion  of  the  handles 
and  controlled  by  a  thumb-screw  enables  the  operator  to  firmly  fix  the 


Figure  2108.    Elliott's  Forceps. 

amount  of  compression, that  undue  pressure  may  be  avoided.  The  fenestra 
is  a  trifle  longer  than  that  of  the  Simpson  forceps,  but  identical  in  form. 
The  width  of  the  cephalic  curve  is  2^  inches,  the  length  of  the  fenestra  5 
inches,  the  height  of  the  pelvic  curve  2^  inches,  and  the  length  of  the  en- 
tire instrument  about  15  inches. 


Figure  2109, 


Leavitt's  Forceps,  as  pictured  in  figure  2109,  do  not  differ  materially  in 
general  shape  from  the  pattern  of  Elliott,  excepting  that  the  handles  are 
curved  downward  on  the  edge,  thus  affording  a  slight  degree  of  what  is 
commonly  termed  axis-traction.  The  handles  are  usually  plain,  with  the 
exception  of  the  lateral  projections.  These,  with  the  curved  form  of  the 
handle,  furnish  all  the  grasping  surface  necessary.  The  length  of  the  fen- 
estra is  about  5  inches,  the  breadth  of  the  cephalic  curve  2^,  and  the  height 
of  the  pelvic  curve  about  2  y^.  inches.  Practically,  the  line  of  the  handle, 
when  averaged,  is  in  a  higher  plane  than  that  of  the  blades,  which  is 
claimed  as  an  advantage  by  the  inventor  of  the  instrument. 


Figure  2110.     Knox's  Axis-Traction  Forceps. 

"^^^^••l^V: 

Knox's  Axis-Traction  Forceps,  as  depicted  in  figure  2110,  have  straight 
handles  with  finger  indentations  and  transverse  projections  similar  to  several 
patterns  previously  mentioned.  The  lock  is  of  English  design,  of  the  mor- 
tise and  tenon  pattern.  The  shanks,  as  in  Simpson's  forceps,  are  spread 
laterally,  the  distances  between  their  inner  margins  being  about  ^  an  inch. 
These  shanks  project  obliquely  downward,  thus  placing  the  blades  of  the 
instrument  on  a  lower  plane  than  the  handle,  the  difference  being  about 


INSTRUMENTAL    DELIVERY.  867 

25^  inches.  The  fenestrae  are  shaped  like  those  of  the  Hodge  forceps,  with 
a  length  of  5  and  a  breadth  of  i^  inches,  while  the  width  of  the  cephalic 
curve  is  about  3  inches.  The  forceps  are  of  heavy  construction  and  pro- 
vided with  a  set  screw  similar  to  that  found  in  the  pattern  of  Elliott.  The 
length  is  about  15  inches. 


Figure  2111.    Tarnier's  Axis-Traction  Forceps. 

Tarnier's  Axis-Traction  Forceps,  as  shown  in  figure  2111,  possess  what 
mechanics  might  call  a  bayonet  curve,  one  in  which  the  long  axis  of  the 
blades  is  parallel,  or  nearly  so,  with  the  handle  line,  but  in  a  different  plane, 
the  difference,  in  this  pattern,  amounting  to  3^  inches. 

Two  hinged  traction  rods  that  can  easily  be  unclasped  are  attached  to 
the  lower  portion  of  the  blades  just  at  the  proximal  border  of  the  fenestrae. 
These  rods  are  affixed  to  projecting  pins  and  have  a  curve  corresponding  to 
that  of  the  shanks  of  the  blades.  The  outer  ends  of  the  traction  rods  are 
united  to  a  bar  curved  downward  and  connected  by  a  swivel  joint  to  a  cross- 
bar that  can  be  turned  in  any  direction.  A  cross-bar  with  winged  nuts 
holds  the  handles  approximate  to  the  fetal  head.  Traction  is  made  by  the 
transverse  handle  alone.  Lusk  claims  to  have  improved  this  pattern  by 
making  the  forceps  lighter  and  devising  a  secure  and  more  easily  adjusted 
attachment  for  the  traction  handle. 


Figure  2112.    Felsenreich's  Modification  of  Tarnier's  Forceps. 

Felsenreich's  Modified  Tarnier's  Forceps,  as  traced  in  figure  2112,  differ 
from  the  original  model  principally  in  the  arrangement  of  the  traction  rods. 
These,  at  their  distal  ends,  are  attached  by  a  loosely  fitting  French  lock, 
detachment  of  which  is  impossible  without  removal  of  the  forceps.  These 
traction  bars,  which  rest  close  to  and  parallel  with  the  blade  shanks,  project 
obliquely  downward  at  a  point  opposite  the  lock,  ending  in  spherical  en- 


868  OBSTETRICAL  SURGERY. 

largements,  by  which  the  transverse  handle  is  detached.  The  bar  of  the 
latter  is  not  only  swiveled,  but  contains  a  lateral  hinge,  that  permits  move- 
ment in  any  direction.  The  spherical  terminals  of  the  traction  rods  rest 
within  two  slots,  in  which  they  may  be  permanently  secured.  A  cross-bar 
and  winged  nut  furnish  means  for  holding  the  blades  locked  and  firmly  in 
place.  The  instrument  is  lighter  than  the  Tarnier  pattern  and  is  about  16 
inches  in  length. 


Jenks'  Short  Forceps. 


Jenks*  Short  Forceps,  as  illustrated  in  figure  2113,  are  about  12  inches  in 
length  and  are  among  the  few  so-called  "pocket"  forceps,  that  may  be 
employed  with  satisfaction  in  a  majority  of  cases  after  the  head  has  reached 
the  floor  of  the  pelvis.  The  handles  are  straight,  with  transverse  projec- 
tions that  furnish  a  good  grasping  surface.  The  lock  is  of  the  mortise  and 
tenon  pattern,  while  the  shanks  project  forward,  one  parallel  with  the  other, 
much  after  the  pattern  of  Simpson.  The  fenestrae  are  narrow  at  their 
proximal  border,  about  4^  inches  in  length,  and  increase  in  width  until  near 
the  tip,  where  they  are  i^  inches  across;  the  cephalic  curve  is  2^  inches 
in  breadth,  while  the  length  of  the  pelvic  curve  is  i  %  inches. 


Figure  2114.    Reynolds'  Axis-Traction  Rods. 

Reynolds'  Axis-Traction  Rods,  as  set  forth  in  figure  2114,  are  intended 
to  supply  axis-traction  to  any  of  the  fenestrated  patterns  of  forceps. 
Practically,  the  rods  are  flattened  bars  with  hooked  or  recurved  distal  ends, 
the  proximal  thirds  being  sharply  curved  downward  on  the  flat.  Each  is 
attached  by  a  cross-bar  to  a  swiveled  hook  that  forms  the  extension  of  the 
transverse  handle.  After  the  forceps  is  in  position  these  rods  may  be 
hooked  into  the  fenestrae  and  many  of  the  advantages  of  the  axis-traction 
forceps  secured. 

As  this  appliance  is  not  only  simple,  light  and  inexpensive,  but  as  it  may 
be  easily  applied  to  any  fenestrated  obstetrical  forceps,  it  furnishes  a  ready 
means  by  which  the  ordinary  obstetrical  may  be  converted  into  an  axis- 
traction  forceps.. 

The  Vectus. 

This  is  practically  one  blade  of  a  forceps  without  pelvic  curve.  It  was 
formerly  employed  to  increase  flexion,  and  where  necessary  to  assist  rota- 
tion, but  is  now  little  used  excepting  occasionally  as  a  lever  or  tractor. 

The  Folding  Vectus,  shown  in  figure  2115,  consists  of  a  curved  fenes- 
trated blade  with  a  strong  shank  and  handle.  Usually,  the  blade  is  about 


APPLIANCES  FOR  HIP   AND  BREECH  PRESENTATIONS. 


869 


2  inches  in  width  by  4  in  length,  with  an  extreme  length,  including  handle, 
of  12  or  13  inches.  It  is  constructed  both  solid  and  folding,  the  latter  only 
appearing  in  the  illustration. 


Figure  2115.    Folding  Vectus. 


APPLIANCES  FOR  HIP  AND  BREECH  PRESENTATIONS. 

These  consist  of  hooks  or  other  mechanism  for  securing  a  hold  on  a  leg 
or  other  similar  part. 

The  Porte-Fillet. 

This  is  a  carrier  for  passing  a  cord  or  bandage  around  the  thigh  or  other 
portion  of  a  fetus.  It  is  especially  employed  in  cases  of  breech  presenta- 
tion. 


Figure  2116.      Oliver's  Porte-Fillet. 

Oliver's  Porte-Fillet,  as  exhibited  in  figure  2116,  consists  of  a  long  tube 
with  a  bulbous  tip,  the  terminal  portion  recurved  to  such  an  extent  that  the 
tip  lies  parallel  with  the  long  axis  of  the  instrument.  The  instrument,  in- 
cluding the  handle,  is  in  tubular  form,  through  which  a  whalebone  stylet 
with  a  metallic  olive-shaped  tip  is  caused  to  pass  backward  and  forward. 
The  extreme  end  of  the  shaft  is  provided  with  a  socket  or  recess,  in  which 
the  metallic  tip  of  the  whalebone  guide  may  be  drawn  during  the  introduc- 
tion of  the  instrument.  That  this  may  be  held  firmly  in  place,  a  binding 
screw  is  provided  in  the  handle.  The  metallic  tip  is  provided  with  an  eye, 
by  which  a  cord  or  ligature  may  be  carried  to  any  desired  point.  When  in 
use,  the  tip  is  carried  around  the  part  to  which  it  is  desired  to  attach  a 
traction  bandage,  the  whalebone  guide  is  projected  forward,  the  metallic 
eye  threaded  with  a  ligature,  withdrawn  into  place,  the  instrument  removed 
and  the  ligature  used  to  draw  the  bandage  into  position. 

Blunt  Hooks. 

These  are  occasionally  employed  for  the  same  purposes  as  the  porte-fillet, 
previously  described.  They  consist  of  strong  shafts,  with  their  distal  ends 
curved  in  hook  form. 

The  Plain  Blunt  Hook,  exhibited  in  figure  2117,  consists  of  a  strong  rod 
and  handle,  the  former,  at  its  distal  end,  curved  in  semi-circular  form. 


870 


OBSTETRICAL  SURGERY. 


Usually,  they  are  provided  with  an  eye,  that  they  may  be  used  to  assist  in 
carrying  a  bandage  around  a  limb  or  other  portion  of  a  fetus. 


Figure  2117.    Plain  Blunt  Hook. 


EMBRYOTOMY. 

The  instruments  required  in  the  various  operations  that  may  be  included 
under  this  head  will  comprise  those  for  craniotomy,  cephalotripsy,  eviscera- 
tion and  decapitation.  The  object  of  all  is  to  diminish  the  size  of  the  fetus 
by  compression  or  subdivision. 

Craniotomy. 

This  will  require  a  perforator  and  craniotomy  forceps,  occasionally 
assisted  by  a  blunt  hook  and  crochet. 

Perforators. 

These  consist  of  spear  or  gimlet-pointed  instruments  used  to  forcibly 
perforate  the  skull.  Generally,  they  are  provided  with  means  for  enlarging 
the  primary  opening.  Sometimes  they  are  used  on  the  trunk  or  spine,  and 
followed  by  heavy  scissors. 


Figure  2118.    Smellie's  Perforator. 


Smellie's  Perforator,  as  described  in  figure  2118,  consists  of  a  short 
spear-pointed  blade  split  through  its  center  by  a  longitudinal  section,  each 
part  forming  the  lateral  half  of  a  scissors-handled  instrument.  Unlike 
scissors,  however,  the  blades  cut  by  forcing  or  drawing  the  handles  apart, 
a  procedure  that  furnishes  but  little  cutting  power.  Shoulders  are  provided, 
to  guard  against  the  introduction  of  the  instrument  to  an  unnecessary  depth. 
As  usually  manufactured,  the  blades  are  about  i^  inches  in  length,  the 
whole  instrument  being  about  10  inches  in  length.  All  the  parts  are  well- 
rounded,  to  avoid  injury  to  the  soft  tissues  of  the  birth-canal.  This  instru- 
ment has  enjoyed  a  large  sale,  not  because  it  is  the  best  of  its  class,  but  on 
account  of  the  low  price  at  which  it  may  usually  be  purchased. 


Figure  2119.    Naegeli's  Perforator. 

Naegeli's  Perforator,  as  depicted  in  figure  2119,  differs  particularly  from 
the  pattern  of  Smellie  in  that  the  blades  are  not  crossing,  so  that  compres- 


EMBRYOTOMY.  871 

sion  of  the  handles  produces  divergence  and  consequent  cutting.  That  the 
forcible  introduction  of  the  instrument  may  not  serve  to  separate  the 
blades  during  perforation,  the  proximal  ends  of  the  handles  are  provided 
with  a  curved  guard  or  keeper,  that,  until  its  release,  prevents  closure  of  the 
handles.  The  blades  are  provided  with  guards  similar  to  the  pattern  before 
described. 


Figure  2120.    Blot's  Perforator. 

Blot's  Perforator,  as  portrayed  in  figure  2120,  consists  of  two  strong 
shafts  hinged  near  their  centers,  one  resting  against  the  other,  the  faces  and 
shape  of  the  two  being  so  nearly  alike  as  to  have  the  appearance  of  a  solid 
instrument.  Their  points  are  spear-shaped  with  sharp  trocar-like  edges, 
the  extreme  point  having  the  form  of  a  diamond-shaped  spear.  One  shaft 
terminates  in  a  fixed  handle ;  the  other  is  curved  upward  and  provided  with 
a  spring,  by  which  the  blades  are  kept  in  contact  or  closed.  After  perfora- 
tion the  blades  may  be  caused  to  diverge  by  compression  of  the  handles, 
thus  enabling  the  operator  to  enlarge  the  opening. 


Figure  2121.    Thomas'  Perforator. 

Thomas'  Perforator,  as  depicted  in  figure  2121,  consists  of  a  straight 
slotted  cylinder  terminating  in  a  double-threaded  conical  screw.  The  slot 
extends  longitudinally  throughout  the  shaft  of  the  instrument,  opening 
upon  one  side  only.  This  serves  to  conceal  a  long-handled  knife,  pro- 
vided with  a  cutting  edge,  at  the  tip  of  its  outer  face.  The  terminal  por- 
tion of  the  knife  blade  is  curved  upward  in  the  form  of  a  handle.  After 
perforation,  by  compression  of  the  lever  handle,  the  primary  incision  may 
be  enlarged. 


Figure  2122.    Braun's  Trephine  Perforator. 

Braun's  Trephine  Perforator,  as  exhibited  in  figure  2122,  consists  of  a 
long  and  slightly-curved  shank  terminating  in  a  cylindrical  head  within  which 
a  trephine  is  caused  to  revolve  by  means  of  a  handle  in  the  proximal  end  of 
the  instrument.  The  trephine  proper  consists  of  a  central  screw  that 
revolves  with  the  trephine  blade.  The  latter  consists  of  sharp  angular  teeth, 
which,  when  pressed  against  the  fetal  skull,  easily  perforate  the  somewhat 
soft  bones.  The  trephine  is  so  arranged  that  the  teeth  and  screw  are  con- 
cealed within  the  instrument  during  its  introduction.  -  By  turning  the 
handle,  the  trephine  not  only  revolves,  but,  by  means  of  a  threaded  screw,  it 


872 


OBSTETRICAL  SURGERY. 


is  gradually  extended  until  perforation  ensues.  This  form  of  perforator  is 
objected  to  by  many,  because  it  is  difficult  to  clean  and  because  its  applica- 
tion is  limited  to  the  cranial  vault. 

Craniotomy  Forceps. 

These  are  employed  for  fracturing  and  breaking  up  the  skull  following 
perforation.  They  consist  of  strongly-built  forceps  usually  with  curved 
jaws. 


Figure  2123.     Meigs'  Craniotomy  Forceps. 

Meigs'  Craniotomy  Forceps,  as  set  forth  in  figure  2123,  have  strong 
handles  and  blades,  the  latter  curved  upward  on  the  edge.  The  jaws 
are  usually  3^  inches  in  length,  the  outer  two-thirds  of  their  inner  surfaces 
being  provided  with  prominent  transverse  teeth. 


Figure  2124.    Thomas'  Craniotomy  Forceps. 

Thomas'  Craniotomy  Forceps,  as  pictured  in  figure  2124,  differ  from  the 
pattern  of  Meigs.  only  in  being  heavier  and  in  having  one  jaw  provided 
with  short,  strong  teeth,  each  about  ^  of  an  inch  in  length.  When  the 
instrument  is  closed,  these  project  into  perforations  upon  the  opposite  blade. 

Crochets. 

These  consist  of  short,  strongly-built  hooks,  employed  to  break  up  the 
skull  and  brain.  Guarded  crochets  are  frequently  offered  for  sale  in  instru- 
ment stores,  the  argument  of  the  salesman  being  that  they  serve  to  protect 
the  mother  from  accidental  injury.  As  a  rule,  their  use  is  unsatisfactory, 
because  they  prevent  perfect  and  rapid  engagement,  and  the  guard  serves 
more  as  a  hindrance  than  an  aid. 


Figure  2125.    Plain  Crochet. 


The  Plain  Crochet,  as  set  forth  in  figure  2125,  consists  of  a  strong  handle 
and  shank,  the  latter  terminating  in  a  short,  sharp  hook  that  projects 
obliquely  backward.  Generally,  the  total  length  is  about  10  inches,  while 
the  length  of  the  hook  is  about  y2  an  inch. 


EMBRYOTOMY.  873' 

The  Blunt  Hook  and  Crochet,  exhibited  in  figure  2126,  is  a  combination 
of  the  two  instruments  before  described.  As  the  value  of  neither  is  affected 
by  this  arrangement,  it  forms  a  desirable  appliance  for  general  use.  It  is 


Figure  2126.     Blunt  Hook  and  Crochet. 


used  to  rotate  a  perforated  head,  and,  in  the  absence  of  a  cranioclast  or  ceph- 
alotribe,  may  be  used  as  a  tractor. 

Cranioclasts. 

These  consist  of  strong  and  powerful  forceps  employed  to  break  up  the 
bones  of  the  fetal  skull  and  for  extraction.  They  differ  from  cephalotribes 
in  that,  when  in  service,  one  blade  is  within  and  the  other  outside  of  the 
skull.  This  necessitates  such  construction  that  the  inner  blade  will  present 
a  convex,  and  the  outer  a  concave  surface  to  the  contacted  parts. 


Figure  212".     Simpson's  Cranioclast 

Simpson's  Cranioclast,  as  pictured  in  figure  2127,  is  practically  an 
enlarged  craniotomy  forceps.  It  differs  from  the  latter,  however,  in  that  one 
of  the  blades  presents  a  large  flaring  fenestra,  the  other  a  convex  surface 
that  fits  into  the  fenestra.  It  is  employed  to  break  up  and  tear  away  the 
bones  of  the  skull  and  for  extraction.  Practically,  it  combines  a  crushing, 
morcellement  and  traction  forceps.  The  handles  are  long  and  provided 
with  indentations  and  projections  that  afford  a  firm  grasp. 


Figure  2128.    Braun's  Cranioclast. 

Braun's  Cranioclast,  as  set  forth  in  figure  2128,  according  to  Munde, 
might  well  be  termed  a  cranio-tractor,  because,  from  its  shape,  it  is  not  con- 
sidered available  for  compression  and  fragmentation,  but  rather  for  traction 
following  the  work  of  the  craniotomy  forceps.  It  is  provided  with  a  pelvic 
curve,  so  that  it  may  be  revolved  only  to  a  limited  degree.  According  to 
Lusk,  its  advantages  as  a  tractor  are  secured  because  of  its  small  size,  as 


OBSTETRICAL  SURGERY. 

one  blade  remains  within  the  perforated  skull  or  unoccupied  space,  while  the 
outer  one  becomes  embedded  in  the  soft  parts,  the  whole  remaining  within 
the  center  of  the  birth-canal.  It  is  constructed  with  a  strong  compression 
cross-bar,  by  which  any  desired  force  may  be  obtained. 

Cephalotripsy. 

This  differs  from  craniotomy,  in  that  the  crushing  instrument  is  also  a 
tractor.  The  instrument  employed  is  called  a  cephalotribe. 

Oephalotribes. 

These  consist  of  powerful  obstetrical  forceps  of  such  size  and  shape  and 
with  such  mechanism  that  a  perforated  fetal  cranium  may  be  compressed 
into  a  small  space. 


Figure  2129.    Lusk's  Cephalotribe. 

Lusk's  Cephalotribe,  as  depicted  in  figure  2129,  is,  in  general  form,  like 
an  obstetrical  forceps,  but  is  constructed  with  handles,  shanks  and  blades 
of  such  strength  that  a  fetal  skull  may  be  crushed  without  regard  to  the 
direction  or  the  aspect  of  the  parts  engaged.  Like  an  obstetrical  forceps, 
it  is  constructed  with  both  cephalic  and  pelvic  curves.  The  blades  are  fen- 
estrated,  the  metallic  rims  of  the  fenestrse  presenting  concave  or  curved 
inner  surfaces  throughout  their  entire  length.  Unlike  an  obstetrical  for- 
ceps, the  tips  of  the  blades  are  in  contact  when  the  instrument  is  closed. 
It  is  constructed  with  a  pin  and  button  lock.  The  crushing  power  consists 
of  a  hinged  cross-bar  attached  to  the  lower  blade,  contact  with  the  upper 
being  secured  by  a  winged  nut.  The  latter  is  provided  with  long  arms, 
which  enable  the  operator  to  employ  powerful  force.  With  this  instru- 
ment the  surgeon  may  seize  the  head,  when  movable,  above  the  pelvic  brim. 
The  instrument  thus  acts  as  a  tractor.  The  cephalic  curve  is  2  inches  in 
breadth,  while  the  pelvic  curve  is  2^  inches  high. 

Evisceration  and  Decapitation. 

These  procedures,  depending  on  the  nature  of  the  case,  usually  require 
the  same  general  instruments  as  are  employed  in  craniotomy.  Decapitation 
may,  however,  be  more  quickly  and  easily  secured  by  the  aid  of  a  special 
hook-shaped  knife. 

Decapitating  Hooks. 

These  consist  of  a  handle  and  long  shank  terminating  in  a  blunt- pointed, 
sickle-shaped  knife. 


Figure  2130.     Ramsbotham's  Decapitating  Hook. 

Ramsbotham's  Decapitating  Hook,  as  shown  in  figure  2130,  consists  of 
a  handle  and  shank  about  16  inches  in  length,  the  distal  end  of  which  is 
curved  to  slightly  more  than  a  right  angle.  The  inner  margin  of  the  curved 
portion  has  a  cutting  edge,  while  the  tip  of  the  blade  is  well  rounded. 


CHAPTER  XXXII. 


SURGERY  OF  THE  RECTUM. 

The  appliances  required  in  treating  diseases  of  the  anus,  rectum 
and  descending  colon  may  be  classified  as  those  for  examinations,  general 
operations,  general  treatment,  treatment  of  fistula,  treatment  of  hemor- 
rhoids, treatment  of  prolapsus,  treatment  of  stricture,  removal  of  polypi, 
and  removal  of  impacted  feces. 


EXAMINATIONS. 

Examinations  will  require  at  least  a  portion  of  the  following: 

Enema  apparatus. 

Appliances  for  anesthesia,  figures  329  to  351. 

Illuminating  apparatus. 

Leg  holder. 

Bougies. 

Sounds. 

Probes. 

Specula. 

Enema  Apparatus. 

Enema  is  usually  secured  with  some  form  of  syringe,  generally  of  the 
bulb  or  fountain  type,  the  latter  preferable  because  less  liable  to  get  out  of 
order.  As  ordinary  forms  of  syringe  pipes  may  be  used  for  this  purpose, 
no  special  descriptions  are  necessary. 

Illuminating  Apparatus. 

Appliances  for  illumination  need  not  differ  from  those  described  by  figures 
1446  to  1470.  Excepting  where  deep-seated  portions  are  under  inspection, 
artificial  light  is  considered  preferable.  The  use  of  a  head  mirror  is  advised, 
and  in  many  cases  an  electric  light  similar  to  that  described  by  figure  1450 
will  be  found  efficient. 

Leg  Holders. 

Almost  any  form  of  leg  holder  may  be  successfully  employed  in  this 
branch  of  surgery.  Specialists  as  a  rule  make  use  of  the  uprights  found  on 
the  Baldwin  and  Edebohl  tables,  as  shown  by  figures  182  and  195,  as  they 
tend  to  relax  the  abdominal  muscles.  The  Kelly  leg  holder  and  Clover's 
crutch,  illustrated  by  figures  196  and  197,  may  also  be  used  to  advantage. 

Bougies. 

These,  in  general  form,  do  not  differ  from  the  patterns  employed  in  ure- 
thral  surgery  excepting  that  they  are  of  much  larger  diameter  as  compared 
with  their  length.  They  are  employed  to  determine  conditions  in  the  rectum 
beyond  the  reach  of  the  finger,  such  as  the  location  of  strictures,  obstruc- 

875 


876 


SURGERY    OF    THE    RECTUM. 


tions,  etc.  Formerly  rigid  or  semi-rigid  varieties  were  used.  These  are  con- 
sidered dangerous  except  in  the  hands  of  experts.  As  a  rule,  none  but  the 
soft  rubber  elastic  bougies  are  now  advised. 


Figure  2131.    Wale's  Soft  Rubber  Rectal  Bougie. 


Wale's  Soft  Rubber  Rectal  Bougie,  sketched  in  figure  2131,  consists  of 
a  cylinder  terminating  in  a  conical  tip  with  an  olive-shaped  point.  An 
opening  that  extends  longitudinally  through  the  instrument  enables  the  sur- 
geon to  inject  the  bowel  with  water  or  other  liquid  during,  or  previous  to, 
the  passage  of  the  instrument.  This  feature  is  an  advantage,  for  frequently 
the  further  progress  of  the  instrument  is  arrested  by  intestinal  folds  that 
may  be  distended  by  injection,  and  thus  pressed  away  from  the  bougie  end. 
The  sizes  generally  adopted  are  as  follows : 

Number  i,  diameter  6  millimeters.     Number  7,  diameter  18  millimeters. 
"        2,          "         8  "  "       8, 

«        10  "  "        9, 


3, 

4- 
5, 
6, 


14 
16 


ii, 

12 


20 

22 

24 
26 
28 


When  the  purchase  is  confined  to  a  single  one,  Number  7  is  recommended. 


Sounds. 


These  consist  of  slender  rigid  instruments,  usually  with  bulbous  points, 
which  are  employed  for  the  same  purposes  as  bougies.  They  are  especially 
useful  in  the  upper  rectum. 


Figure  2132.    Hall's  Rectal  Sound  or  Searcher. 

Hall's  Rectal  Sound  or  Searcher,  as  portrayed  in  figure  2132,  consists  of  a 
rod-like  shaft  in  sigmoid  shape,  one  end  of  which  is  in  loop  form,  while  the 
other  terminates  in  an  acorn-shaped  bulb.  Usually  the  loop  is  about  i  inch, 
and  the  bulb  ^  an  inch,  in  external  diameter,  while  the  total  length 
of  the  instrument  is  about  1 2  inches. 

Probes. 

Probes  for  use  in  this  branch  of  surgery  do  not  differ  materially  from 
those  employed  in  gynecology. 


Figure  2133.    Plain  Silver  Probe. 

The  Probe,  exhibited  in  figure  2133,  is  made  from  soft  silver,  and  is  about 
8  inches  in  length,  exclusive  of  the  handle. 

Specula. 

These  are  employed  to  expose  the  rectal  pouch  in  examinations  and 
applications,  and  as  dilators. 


EXAMINATIONS. 


877 


These  may  be  classified  in  the  same  manner  as  those  employed  in  gyne- 
cological surgery;  namely,  tubular,  uni- valve  and  multi-valve. 

Tubular  Specula  may  be  procured  in  a  variety  of  forms.  Some  are  plain, 
with  the  exception  of  an  obturator  that  assists  in  introduction.  Quite  a 
number  are  finished  with  fenestrae,  while  a  third  variety  is  provided  with 
long  slots  that  may  be  utilized  to  inspect  the  rectal  walls. 


Figure  2134.    Kelly's  Long  Proctoscope. 


Figure  2135.     Kelly  s  Sigmoidoscope. 


Figure  2136.    Kelly's  Speculum. 


Figure  2137.     Kelly's  Short  Proctoscope. 


Kelly's  Specula,  the  longer  patterns  of  which,  shown  by  figures  2134, 
2135  and  2136,  are  known  as  proctoscopes  and  sigmoidoscopes,  differ  from 
each  other  only  in  diameter  and  length.  As  these  are  employed  both  for 
examinations  and  operations,  not  only  in  the  rectum,  but  in  the  lower  portion 
of  the  bowel,  a  variety  of  lengths  is  necessary.  As  the  largest  diameter 
permissible  should  be  used  in  each  case,  an  assortment  of  sizes  of  each  length 
would  be  convenient.  Kelly  employs  a  set  of  54,  assorted  with  a  view  to 
utilizing  in  each  case  a  speculum  not  only  of  the  exact  length  required, 
but  of  the  largest  diameter  permissible.  When  only  a  limited  number  are 
purchased,  he  advises  three  specula;  namely:  One  short  proctoscope  22  mil- 


878  SURGERY  OF  THE  RECTUM. 

limeters  in  diameter  and  5  y2  inches  long ;  one  long  proctoscope  of  the  same 
diameter  and  8  inches  long,  and  one  sigmoidoscope  of  the  same  diameter  and 
1 4  inches  long.  All  are  provided  with  obturators,  without  which  introduction 
would  be  painful  and  often  dangerous.  These  consist  of  acorn-shaped  points 
attached  to  rods  that  are  manipulated  by  proper  handles.  In  the  longer 
patterns,  small  discs  are  located  at  different  points,  that,  in  the  introduc- 
tion and  withdrawal  of  the  obturator,  the  handle  may  be  kept  in  a  line  with 
the  long  axis  of  the  instrument.  If  this  is  not  done,  the  bulb  may  become 
wedged  in  the  tube,  producing  more  or  less  jarring  sensation  and  annoyance. 
Some  of  the  longer  patterns  are  provided  with  detachable  handles,  that 
they  may  be  more  easily  packed  for  transportation.  Generally  the  proximal 
end's  are  made  flaring,  not  only  to  facilitate  the  passage  of  the  obturator, 
but  also  the  introduction  of  light  rays  and  instruments. 


Figure  2138.    Ives'  Speculum 


Ives'  Speculum,  as  detailed  in  figure  2138,  consists  of  a  truncated  cone, 
one  side  of  which  is  cut  away  at  its  distal  end,  leaving  an  opening  embrac- 
ing nearly  one-half  the  diameter  of  the  tube  and  about  two-fifths  of  its 
length.  A  hard  rubber  obturator  closely  fits  the  tube,  extending  about 
half  an  inch  beyond  its  terminal  point,  by  means  of  which  easy  introduc- 
tion of  the  instrument  is  effected.  After  the  withdrawal  of  the  obturator, 
the  rectal  walls  collapse  within  the  slotted  portion,  and  may  be  readily  exam- 
ined. Usually  these  specula  are  manufactured  in  three  sizes,  known  as 
small  medium  and  large. 


Figure  2139.    Allingham's  Speculum. 

Allingham's  Speculum,  as  shown  in  figure  2139,  consists  of  a  truncated 
flaring  cone  with  an  obliquely-cut  distal  end,  the  lower  border  of  which 
opens  in  the  form  of  a  slot  that  extends  throughout  the  entire  length  of  the 
instrument.  The  width  of  this  slot  is  about  one-quarter  of  the  circumference 
of  the  whole.  The  distal  margins  are  turned  in  to  present  a  smooth  surface 
for  introduction.  A  hard  rubber  obturator  completely  fills  the  instrument. 
After  the  obturator  is  withdrawn,  the  longitudinal  slot  permits  an  examina- 
tion of  the  rectal  walls  at  any  point. 

Aloe's  Rectal  Speculum,  as  exhibited  in  figure  2140,  is  a  metallic  cylinder 
surmounted  by  a  hard  rubber  conical  tip.  One  side  of  the  cylinder  con» 
sists  of  a  slide  that,  when  withdrawn,  leaves  a  fenestra  occupying  about  one- 
fourth  of  the  circumference  of  the  instrument.  The  distal  end  of  the  spec- 


EXAMINATIONS. 


879 


ulum  chamber  is  filled  with  a  mirror  placed  at  an  angle  of  1 35°,  which  serves 
not  only  as  a  reflecting  surface,  but  to  prevent  the  mucous  membrane  from 
becoming  engaged  in  the  border  of  the  fenestra  when  the  instrument  is 
withdrawn.  As  the  slide  may  be  wholly  or  partially  removed,  the  instru- 
ment may  be  used  for  both  examinations  and  operations.  It  offers  the 


Figure  2140.    Aloe's  Rectal  Speculum. 


advantage  that  a  limited  section  of  the  mucous  membrane  maybe  exposed, 
to  the  exclusion  of  other  parts.  The  instrument  is  manufactured  in  three 
sizes :  The  small,  ^  °f  an  incn  in  diameter  and  4  inches  in  length ;  the 
medium,  "fa  of  an  inch  in  diameter  and  5  inches  in  length,  and  the  large, 
i  inch  in  diameter  and  5  y2  inches  in  length. 

Uni-Valve  Specula  do  not  differ  from  those  employed  in  gynecology, 
the  deeper  patterns  of  Sims'  designs  being  generally  preferred. 

Multi- Valve  Specula  may  be  obtained  in  great  variety,  those  with  more 
than  three  blades  being  seldom  employed. 


Figure  2141.     Bodenheimer's  Speculum. 


Figure  2142.     Sims'  Speculum. 


Bodenheimer's  Speculum,  as  portrayed  in  figure  2141,  is  one  of  the  oldest 
yet  least  serviceable  patterns  among  this  class  of  instruments.  As  usually 
manufactured,  it  consists  of  two  jointed  handles  and  shanks,  terminating  in 
long,  slender  blades  that  project  nearly  at  a  right  angle.  Ordinarily  the  blades 
are  tapering,  about  y2  an  inch  in  width  at  their  tips  and  ^  of  an  inch  in 
width  at  their  bases,  with  a  length  of  4  inches.  As  generally  sold,  the 
instrument  is  of  cheap  construction,  its  chief  advantage  being  that  it  can 
be  purchased  at  a  low  price.  It  is  not  only  too  narrow,  but  not  strong 
enough  to  use  as  a  dilator. 

Sims'  Speculum,  as  pictured  in  figure  2142,  consists  of  two  long  steel 
handles  that  terminate  in  strong  wire  blades  projecting  at  a  right  angle 
These  blades  are  in  the  form  of  loops,  and  are  each  about  i  inch  in  breadth 
by  4  inches  in  length  Any  amount  of  dilatation  secured  may  be  main- 
tained by  a  set  screw.  As  the  wires  occupy  but  little  space  when  pressed 
against  the  rectal  wall,  the  instrument  admits  of  a  thorough  examination 
of  the  parts. 


.880  SURGERY    OF    THE    RECTUM. 

Kelsey's  Speculum,  according  to.figure  2143,  consists  of  a  Cusco's  vaginal 
speculum,  the  upper  blade  of  which  is  changed  from  a  flat  surface  to  an 
open  fenestra,  the  enclosing  blade  borders  being  so  slender  that  they  are 
.almost  in  rod  form.  The  instrument  is  well  adapted  for  both  examinations 


Figure  2143.    Kelsey's  Speculum.  Figure  2144.    Henderson's  Speculum. 


and  applications.  The  width  of  the  blades  is  usually  about  i  inch,  with  a 
length  of  4  inches.  The  handles  are  jointed,  that  they  may  be  folded  for 
transportation. 

Henderson's  Speculum,  as  illustrated  in  figure  2144,  is  designed  after  the 
pattern  of  Bodenheimer,  but  with  shorter  and  stronger  blades  and  shanks. 
As  generally  manufactured,  the  blades  are  about  3  inches  in  length,  conical 
in  form,  and  i  inch  in  diameter  at  their  bases.  When  closed,  the  instrument 
may  be  easily  introduced,  and  is  of  sufficient  strength  to  be  used  as  a  dilator. 
This  pattern  is  useful  not  only  for  operating  purposes,  but  for  office  practice. 


Pratt's  Bi-Valve  Speculum. 


Pratt' s  Bi-Valve  Speculum,  as  portrayed  in  figure  2145,  is  one  of  the 
largest  and  strongest  instruments  of  its  class.  As  usually  manufactured, 
the  blades  are  3  inches  in  length  by  i  inch  in  breadth.  The  tips,  when  the 
instrument  is  closed,  present  a  well-rounded  oval  that  is  ^  of  an  inch  in 
width,  a  short  distance  from  the  end  of  the  instrument.  This  speculum  is 
employed  by  its  inventor  as  a  dilator,  and  for  this  purpose  it  is  manufac- 
tured with  handles  of  good  length  and  firm  construction. 

Mathews'  Speculum,  as  represented  in  figure  2146,  consists  of  two  fen- 
estrated  blades,  the  principal  features  of  which  are  a  constriction  or  narrow- 
ing of  that  portion  of  the  instrument  engaged  by  the  sphincter  ani,  and  a 
conical  tip  of  such  form  as  to  be  easily  introduced.  The  handles  are  short, 
strongly  built,  and  attached  to  the  blades  at  nearly  a  right  angle.  A  cross- 
bar and  nut  maintain  any  desired  degree  of  expansion.  The  whole  instru- 
ment is  of  strong  construction,  and,  as  the  blades  present  a  flattened  surface 


GENERAL    TREATMENT. 


881 


to  the  mucous  membrane,  it  may  be  used  to  secure  dilatation  as  well  as  for 
the  ordinary  purposes  of  a  speculum. 


Figure  2140.    Mathews'  Speculum. 


Cook's  Speculum,  as  traced  in  figure  2147,  consists  of  three  steel  blades 
that,  by  means  of  a  toggle  joint,  actuate  simultaneously  by  compression  of 
the  handles.  By  this  movement,  the  two  outer  or  lateral  blades  are  not  only 
separated,  but  the  lower,  or  anterior,  one  is  retracted.  A  ratchet  bar  and 


Figure  2147.    Cook's  Speculum. 


spring  serve  to  catch  and  hold  any  secured  degree  of  dilatation.  Owing 
to  the  extreme  distance  between  the  tips  of  the  blades  and  the  fulcrum, 
this  instrument  is  useless  unless  forged  from  steel ;  and  physicians,  in  pur- 
chasing, should  guard  against  the  substitution  of  softer  metal. 


GENERAL  TREATMENT. 

General  treatment  may  necessitate  the  employment  of  any  of  the  follow- 
ing appliances: 

Syringe,  figures  693  to  696. 

Rectal  tube  for  injections  above  the  sigmoid  flexure. 

Insufflator  for  the  application  of  powder,  figures  1505  to  1510. 

50 


882  SURGERY    OF    THE    RECTUM. 

Pipe  or  tube  for  applying  ointment. 

Packing  instruments. 

Electric  battery  and  electrodes. 

Rectal  Tubes. 
These  consist  of  long  soft  rubber  tubes,  preferably  with  firm  walls. 


Figure  2147 A.    Plain  Rectal  Tube. 

The  Plain  Rectal  Tube  exhibited  in  figure  2 147 A  is  usually  about  30 
inches  in  length,  of  No.  32  to  35  French  scale,  and  is  provided  with  an  outlet 
in  its  extreme  end.  The  walls  are  heavy,  that  the  instrument  may  offer 
firm  yet  elastic  resistance  to  any  obstruction. 


Figure  2148.    Ointment  Pipe. 

The  Ointment  Pipe,  displayed  in  figure  2148,  consists  of  a  slender  cylin- 
drical tip,  the  proximal  portion  of  which  is  enlarged  to  form  a  deep  cylin- 
drical chamber  for  the  reception  of  the  ointment  to  be  injected.  The  lateral 
margins  of  the  tip  are  provided  with  perforations,  through  which  the  oint- 
ment is  forced.  After  the  chamber  has  been  filled,  a  screw  plug  may  be 
inserted  in  its  base,  the  plug  being  of  sufficient  size  to  fill  the  chamber, 
thus  forcing  the  ointment  out  through  the  openings  referred  to.  After 
filling  the  chamber  and  placing  the  plug  in  position,  by  turning  the  screw, 
any  desired  amount  of  the  ointment  may  be  applied. 


Figure  2149.    Turck's  Flexible  Colonic  Sound  and  Irrigator. 


Turck's  Flexible  Colonic  Sound  and  Irrigator,  as  set  forth  in  figure  2149, 
consists  of  a  double-curved  flexible  metallic  tube  about  16  inches  in  length, 
of  such  design'  and  construction  that  it  may  be  passed  through  the  sigmoid 
flexure.  It  is  not  only  in  sigmoid  shape,  but  is  also  curved  laterally,  some- 
what in  helical  form.  This  tube  serves  not  only  as  a  channel  for  the  return 
flow  of  any  fluids  that  may  be  injected  through  it,  but  as  a  sheath  for  the 


GENERAL    TREATMENT. 


883 


introduction  of  a  flexible,  hollow,  metallic  cable  that  forms  a  portion  of  the 
instrument.  The  distal  end  of  this  cable  is  surmounted  by  an  olive- shaped, 
perforated  head  which  serves  as  a  pathfinder  or  guide  for  the  passing  of 
the  sound.  As  the  latter  is  hollow,  it  may  be  employed  as  a  means  for  the 
injection  of  either  air  or  water,  which  may  be  employed  for  colonic  disten- 
tion,  and  this,  if  secured  during  the  passage  of  the  sound,  will  assist  in  its 
further  introduction  With  little  effort  this  tube  may  be  caused  to  follow 
the  curves  of  the  colon  as  far  as  the  cecum.  The  position  of  the  cable  tip 
may  be  determined  by  palpation,  particularly  if  the  cable  be  slightly  rotated. 
As  the  cable  is  made  from  metal,  it  may  be  employed  as  an  electrode  when 
necessary. 


Figure  2150.     Kelly's  Dressing  Forceps. 


Kelly's  Dressing  Forceps,  as  depicted  in  figure  2150,  have  double-crossing 
spring  handles,  with  long  slender  shanks  and  jaws  that  are  transversely 
serrated.  As  the  instrument  is  self-closing,  it  is  opened  by  compression  of 
the  spring.  It  is  angular  bent,  the  length  of  the  blade  portion  being  9 
inches,  with  a  total  length  of  14  inches.  It  is  employed  for  making  topical 
applications  to  the  upper  portion  of  the  rectum  through  a  speculum,  and  for 
cleansing  the  rectum  by  pledgets  of  cotton. 

Packing  Instruments. 

These  need  not  differ  from  those  employed  in  packing  the  uterus  except- 
ing that  they  should  be  longer. 
" 


Figure  2151.     Kelly's  Packer. 

Kelly's  Packer,  as  outlined  in  figure  2151,  consists  of  a  long,  delicate  shaft 
with  handle  bent  downward.  Its  tip  terminates  in  a  double  fork  of  a  size 
and  shape  suited  to  placing  and  firmly  wedging  gauze  tampons.  It  is 
employed  for  packing  the  upper  portion  of  the  rectum. 

Electrical  Treatment. 

This  may  be  secured  with  any  of  the  batteries  described  by  figures  446 
to  454.  Special  electrodes  are  generally  employed. 


Figure  2152.     Rectal  Electrode. 

The  Rectal  Electrode,  exhibited  by  figure  2152,  consists  of  a  somewhat 
slender  shaft  about  5  inches  in  length  with  an  elongated  bulb-shaped  tip. 


884 


SURGERY    OF    THE    RECTUM. 


They  may  be  procured  plain,  with  the  stem  insulated,  with  one  lateral 
longitudinal  half  insulated,  or  bi-polar;  that  is,  with  an  insulated  section 
extending-  from  end  to  end,  each  side  of  which  may  be  connected  with  a 
battery  pole. 


Figure  2153.     Ball  Electrode. 


The  Ball  Electrode,  traced  in  figure  2153,  is  a  straight  insulated  stem 
about  6  inches  in  length,  terminating  in  a  metallic  sphere  about  s/8  of  an 
inch  in  diameter.  While  this  size  is  generally  employed,  they  may  be 
procured  of  any  size  desired. 


GENERAL  OPERATIONS. 

The  instruments  required  in  general  operations  will  include : 

Illuminating  apparatus,  figures  1446  to  1470. 

Leg  holder,  figures  182  to  197. 

Specula,  figures  2134  and  2147. 

Sponge  holders. 

Dressing  and  packing  forceps,  figure  2150. 

Tenaculum. 


TRUAX-CRELNE-CO 


Figure  2154.    Kelly's  Sponge  Holder. 

Kelly's  Sponge  Holder,  as  displayed  in  figure  2154,  while  constructed  simi- 
larly to  the  pattern  of  Sims,  is  provided  with  a  larger  handle,  thus  securing 
better  control.  The  latter  is  angular-bent  downward,  while  the  jaws  are 
heavier  and  are  provided  with  seven  instead  of  three  mouse-teeth.  The 
instrument  is  about  21  inches  in  length. 


Figure  2155.     Hall's  Dressing  and  Packing  Forceps. 

Hall's  Dressing  and  Packing  Forceps,  as  shown  in  figure  2155,  do  not 
differ  from  the  pattern  of  Bozeman,  excepting  that  they  are  much  longer, 
generally  about  13  inches. 


Figure  2156.     Kelly's  Tenaculum. 


Kelly's  Tenaculum,  as  illustrated  in  figure  2156,  does  not  differ  from  the 
regular  patterns  except  that  it  is  more  strongly  built  and  about  13  inches 
in  length.  It  may  be  employed  to  advantage  in  many  rectal  operations. 


TREATMENT    OF    FISTULA.  885 

TREATMENT   OF  FISTULA. 

The  instruments  required  in  the  treatment  of  fistula  may  be  classified 
as  those  for  caustic  injection,  scarification,  excision  of  tract,  incision,  and 
elastic  ecrasement. 

Caustic  Injection. 

Caustic  injection  along  the  sinus  canal  may  be  secured  by  means  of  a 
hypodermic  syringe  and  blunt- pointed  needle.  The  latter  may  be  of  steel 
and  rigid,  or  of  silver  soft  and  flexible.  The  canula  devised  by  Ingals  and 
used  in  the  introduction  of  cocaine  may  be  employed  to  advantage.  It  is 
shown  in  figure  2157. 


Figure  2157.     Ingals'  Cocaine  Canula. 

Ingals'  Cocaine  Canula,  as  generally  employed  in  surgery  of  the  nose,  is 
admirably  adapted  for  this  purpose.  As  exhibited  in  figure  2157,  it  consists 
of  a  soft,  elastic  probe-pointed  tube,  generally  from  4^  to  6  inches  in  length, 
which  may  be  curved  to  any  desired  shape. 

Scarification. 

Scarification  in  the  treatment  of  fistula,  consists  in  making  lateral 
incisions  throughout  the  length  of  the  sinus,  with  the  hope  that  the  entire 
opening  may  become  permanently  obliterated  with  the  healing  of  the  sur- 
gical wound.  The  instruments  generally  employed  for  this  purpose  are 
called  fistulatomes.  The  operation  is  usually  performed  without  the  use  of 
a  general  anesthetic,  cocaine  being  injected  into  the  sinus  throughout  its 
entire  length. 

Fistulatomes. 

These  are  usually  slender  and  somewhat  flexible  instruments,  provided 
with  concealed  or  otherwise  guarded  blades  which,  by  the  operation  of  screw 
mechanism,  may  be  caused  to  emerge  or  protrude,  and  may  thus  be  used  to 
produce  lateral  incisions.  After  the  introduction  of  the  instrument  through 
the  sinus,  the  walls  may  be  slit  throughout  their  whole  length  by  dilating 
the  blades  and  withdrawing  the  instrument. 


Figure  2158.    Mathews'  Fistulatome. 

Mathews'  Fistulatome,  as  shown  in  figure  2158,  consists  of  a  slender 
tube  provided  with  an  inner  rod,  to  the  distal  end  of  which  narrow  lateral 
knives  are  attached.  During  introduction,  these  blades  are  wholly  concealed 
within  the  tube,  the  tissues  being  thus  guarded  from  accidental  injury. 
By  means  of  a  thumb-screw  in  the  handle  of  the  instrument,  the  blades  may 
be  laterally  projected  to  any  desired  extent.  After  being  passed  within  the 
canal,  any  width  of  incision  from  6  to  12  millimeters  may  be  obtained.  A 
scale  in  the  handle  accurately  marks  the  distance  between  the  extreme  edges 
of  the  cutting  blades.  As  generally  manufactured,  the  shaft  is  about  6% 
inches,  and  the  whole  instrument  about  9^  inches  in  length. 


SURGERY    OF    THE    RECTUM. 


Excision. 

Excision  of  the  fistulous  tract  will  require  the  general  rectal  instru- 
ments described  on  pages  884  and  the  minor  operating  instruments  as  de- 
scribed on  pages  2 70  to  275. 

Incision. 

The  appliances  necessary  comprise  the  general  instruments  described  on 
pages  270  to  275  with  the  addition  of  tenaculum  forceps,  figure  1021,  probe, 
knife,  scissors,  director  and  gorget  or  some  form  of  rectal  plug. 

Probes. 

While  these  need  not  differ  from  those  employed  in  surgical  gynecology, 
those  with  delicate  and  slender  necks  may  often  be  employed  to  advantage. 


Figure  2159.     Kelsey's  Probe. 

Kelsey's  Probe,  the  shape  of  which  is  made  clear  by  figure  2159,  is  made 
from  soft  silver,  with  a  delicate,  tapering  shaft  terminating  in  a  small  olive- 
shaped  tip.  It  may  be  used  to  advantage  in  exploring  minute  and  tortuous 
sinus  tracts. 

Knives. 

Knives  for  fistula  incisions  may  be  either  sharp  or  probe-pointed. 
Formerly,  complicated  patterns,  some  with  guarded  blades  and  others  to 
be  used  in  connection  with  rectal  plugs,  were  advised.  In  modern  surgery, 
however,  selections  are  usually  made  from  among  the  ordinary  bistouries, 
such  as  are  described  by  figures  549  to  597.  They  are  generally  employed 
in  connection  with  a  grooved  director. 


Figure  2160.     Sharp-Pointed  Bistoury  for 
Incision  of  Fistula. 


Figure  2161.     Blunt-Pointed  Bistoury  for 
Incision  of  Fistula. 


The  Curved  Bistouries,  shown  in  figures  2160  and  2161,  differ  from  each 
other  only  in  the  shape  of  the  points ;  one  being  sharp,  the  other  blunt. 
Occasionally  straight  knives  are  employed,  while  those  of  special  design 
are  not  uncommon. 

Scissors. 

Scissors  for  cutting  through  fistula  walls  should  be  constructed  with 
sharp,  strong  blades  and  one  sharp  point.  They  are  usually  employed  in 
connection  with  a  grooved  director. 


Figure  21R2.     Sharp-Pointed  Scissors  for  Fistula  Incision. 


The  Sharp-Pointed  Scissors,  illustrated  in  figure  2162,  do  not  differ  from 
those  employed  in  many  gynecological  operations.  Those  about  8  inches 
in  length  will  be  found  most  serviceable. 


TREATMENT    OF    FISTULA. 

Directors. 


887 


Directors  are  required,  not  only  for  locating  the  sinus  during  the  incision, 
but  to  assist  in  guiding  the  knife,  that  tissues  other  than  those  forming  the 
bridge  may  not  be  injured.  Usually  a  flexible  instrument  with  probe-point 
is  preferred.  • 


Figure  2163.    Probe-Pointed  Fistula  Director. 

The  Probe-Pointed  Fistula  Director,  exhibited  in  figure  2163,  consists  of  a 
slender  shaft  about  4^  inches  in  length,  with  one  end  flattened  and  bent 
downward  at  an  angle  of  45°  to  serve  as  a  handle,  the  other  terminating  in 
an  olive-shaped  point  with  slender  neck.  The  upper  margin  is  in  the  form 
of  a  deep  groove  so  shaped  as  to  serve  as  a  guide  for  the  knife  with 
which  the  incision  is  made.  They  should  be  constructed  either  from  soft 
silver  or  copper,  that  they  may  be  curved  as  desired. 

Gorgets. 

Some  form  of  rectal  plug  or  other  blunt  instrument  is  usually  employed, 
against  which  the  point  of  the  knife  may  strike  when  incision  of  the  tissue 
is  completed.  If  a  blunt  or  probe-pointed  bistoury  is  used,  the  operator  may 
use  the  finger  to  protect  the  soft  tissues  of  the  opposite  wall  against  injury. 
If  a  sharp  bistoury  is  used,  a  special  instrument  should  be  employed  to 
protect  the  opposite  wall. 


Figure  2164.    Gorget  for  use  in  Fistula  Incision. 

The  Gorget,  shown  in  figure  2164,  is  of  metal  y?  an  inch  in  width  and 
about  8  inches  in  length.  It  is  of  such  form  as  not  to  injure  the  soft  tissues, 
and  is  intended  to  be  used  as  a  guard  to  receive  the  point  of  the  knife  used 
in  the  fistula  incision. 

Ecrasement. 

This  consists  in  passing  a  rubber  ligature  through  the  sinus  into  the 
bowel  and  out  through  the  rectum,  tightly  drawing  the  ligature  and  tying 
the  ends  together.  The  object  is  to  cut  through  all  enclosed  tissues  by 
elastic  tension.  The  only  special  instruments  required  are  ligature  carriers. 


Figure  2165.    Allingham's  Ligature  Carrier. 


Allingham's  Ligature  Carrier,  as  illustrated  in  figure  2165,  consists  of  a 
slender  tube  provided  with  an  inner  rod  that  may  be  moved  backward  and 
forward  by  a  thumb-piece.  Near  the  distal  end  a  section  in  the  outer  tube 


SURGERY    OF    THE    RECTUM. 


forms  an  opening  and  closing  eye  that  may  be  used  to  clamp  and  hold  an 
elastic  ligature.  The  instrument  is  provided  with  two  tips,  one  sharp,  the 
other  blunt,  to  be  used  in  different  classes  of  cases.  If  this  instrument  can 
be  passed  through  a  sinus,  a  ligature  may  be  carried  into  the  bowel,  where 
it  may  be  released  from  the  grasp  of  the  carrier  with  a  pair  of  dressing  for- 
ceps and  drawn  out  through  the  rectum. 


TREATMENT   OF  EXTERNAL  HEMORRHOIDS. 

External  hemorrhoids  may  be  treated  by  incision  or  excision.  The 
former  operation,  which  is  usually  attended  with  enucleation,  requires  no 
other  instruments  than  a  sharp-pointed  bistoury,  an  artery  forceps,  and  a 
ligature  when  necessary  to  prevent  hemorrhage. 

Excision  is  usually  secured  by  volsellum  forceps,  scissors,  hemostatic 
forceps  and  ligature,  no  special  instruments  being  necessary. 


TREATMENT  OF  INTERNAL  HEMORRHOIDS. 

Internal  hemorrhoids  may  be  treated  by  injection,  ligation,  clamp  and 
cautery,  crushing  or  dilatation. 

Injection. 

Injection  may  be  made  with  a  hypodermic  syringe,  with  needles  of  large 
size.     A  pattern  that  may  be  easily  sterilized  is  much  to  be  preferred. 


Figure  2166.     Hypodermic  Syringe  for  Hemorrhoidal  Injections. 

The  Hypodermic  Syringe,  illustrated  by  figure  2166,  is  advised  for  this 
operation,  because  it  is  not  only  usually  accompanied  by  needles  of  large 
size,  but  may  be  easily  sterilized.  As  it  has  been  more  fully  described 
on  page  194,  no  further  description  is  here  required. 

Ligation. 

The  ligation  of  internal  hemorrhoids  will  require  retractors  or  speculum, 
to  expose  the  operating  field ;  small  volsellum  forceps,  to  seize  and  draw 
down  the  tumor;  scissors  or  knife  for  dissecting  around  and  dividing  the 
mass  from  its  attachments;  delicate  knife  for  incision,  and  ligatures  and 
ligature  earner. 


TREATMENT    OF    INTERNAL    HEMORRHOIDS 


8S9 


Retractors. 


Retractors  for  use  in  this  operation  should  be  constructed  with  narrow 
blades,  flat  or  nearly  so,  and  bent  at  about  a  right  angle  with  the  handle. 
They  are  usually  employed  in  pairs. 


Figure  2167.    Pratt's  Retractor. 


Pratt's  Retractor  consists  of  a  handle,  slender  shank  and  loop-shaped 
blade,  the  face  of  the  latter  being  bent  at  a  right  angle  with  the  long  axis 
of  the  instrument.  The  width  of  the  blade  is  usually  about  1^4  inches,  while 
the  length  of  the  fenestrated  portion  is  about  2  inches.  It  is  illustrated 
in  figure  2167. 


Figure  2168     Plain  Retractor. 


The  Plain  Retractor,  delineated  in  figure  2168,  have  well-rounded 
blades  about  i  inch  in  width,  bent  at  a  right  angle  and  with  a  retracting 
suface  about  3  inches  in  length. 

Volsellum  Forceps. 

These  differ  from  the  patterns  employed  in  gynecological  surgery  only  in 
being  of  more  delicate  construction. 


Figure  2169.    Pratt's  Volsellum  Forceps. 


Pratt's  Volsellum  Forceps,  as  drawn  in  figure  2169,  have  long  and  slender 
shanks,  with  fine,  sharp-hooked  teeth,  two  upon  each  blade,  all  slightly 
recurved.  This  shape  affords  a  firm  grasp  with  the  exercise  of  limited 
force. 

Ligature  Carriers. 

These  are  sometimes  required  in  the  adjustment  of  ligatures.       They 
0 = 

Figure  2170.     Plain  Ligature  Carrier. 

usually  consist  of  some  form  of  a  loop  or  hook,  by  means  of  which  a  thread 
may  be  engaged  or  loosened  without  withdrawing  the  instrument. 


890 


SURGERY    OF    THE    RECTUM. 


The  Plain  Ligature  Carrier,  displayed  in  figure  2170,  is  a  slender  shaft, 
the  tip  of  which  is  turned  in  an  open  loop  so  shaped  that  it  may  be  threaded 
by  passing  a  ligature  at  any  point  of  its  -length  between  the  coils  of  the 
wire. 

Clamp  and  Cautery. 

The  removal  of  hemorrhoids  by  clamp  and  cautery  requires  volsellum 
forceps,  to  seize  and  draw  down  the  hemorrhoid ;  scissors  to  partially  dissect 
it  from  its  base ;  clamps  for  compression  of  stump,  and  cautery  for  excision. 

Volsellum  Forceps. 

These  instruments  for  manipulating  hemorrhoids  are  usually  constructed 
with  a  number  of  fine,  sharp  teeth  that  supply  a  large  grasping  surface. 


Mathews'  Volsellum  Forceps. 


Figure  2171. 


Mathews'  Volsellum  Forceps,  as  detailed  in  figure  2171,  have  broad  fen- 
estrated  jaws  curved  inward  on  the  edge.  The  distal  margins  are  straight, 
at  right  angles  with  the  axis  of  the  instrument  and  are  provided  with  fine 
teeth  similar  to,  but  not  as  sharp  as,  those  employed  in  tissue  forceps. 


Figure  2172.     Pratt's  Hemorrhoidal  Scissors. 


Pratt's  Hemorrhoidal  Scissors,  as  outlined  in  figure  2172,  are  of  heavy 
construction,  with  short  strong  blades,  curved  on  the  flat  and  with  sharp 
points.  As  they  may  be  used  to  advantage  in  many  other  operations,  they 
form  a  desirable  pattern  for  surgical  use. 

i 

Clamps. 

Clamps  for  use  with  cautery  are  practically  forceps  with  extra  heavy 
jaws,  and  handles  closed  and  controlled  by  screw-power.  They  are  used  as 
provisional  ligatures  to  prevent  hemorrhage  during  excision  by  cautery. 


Figure  2173.    Smith's  Cautery  Clamp. 


Smith's  Cautery  Clamp,  as  disclosed  in  figure  2173,  has  broad,  flattened 
compression  blades,  the  shanks  of  which  are  in  bayonet  form.  The  contact 
surfaces  of  the  blades  are  of  the  tongue-and- groove  pattern,  that  the  crush- 
ing of  the  vessels  may  be  accompanied  by  the  greatest  possible  amount  of 


TREATMENT  OF  INTERNAL  HEMORRHOIDS. 


891 


laceration.  Each  of  the  blades,  on  its  outer  surface,  is  covered  with  an  ivory 
plate  or  shield  to  prevent  radiation  of  heat  from  the  steel  portion  of  the 
instrument  to  the  healthy  tissues.  When  in  use,  the  stump  is  seized 
between  the  blades,  tightly  compressed  and  secured  by  means  of  a  cross- 
bar and  nut,  as  shown  in  the  illustration.  The  cautery  should  be  applied 
along  the  metallic  side  of  the  jaw. 


Figure  2,174.     Kelsey's  Clamp. 

Kelsey's  Pile  Clamp,  as  pictured  in  figure  2174,  differs  from  the  pattern 
of  Smith  in  that  the  blades  are  slightly  curved  on  the  flat,  are  as  thin  as  is 
consistent  with  the  necessary  strength  and  are  without  the  ivory  plates, 
which  are  deemed  unnecessary.  The  margins  of  the  closed  instrument 
are  well  smoothed  and  rounded,  that  injury  to  sound  tissues  may  be  avoided. 


Figure  2175.    Oviatt's  Clamp. 

Oviatt's  Clamp,  an  illustration  of  which  appears  in  figure  2175,  while 
it  resembles  the  pattern  of  Smith  in  general  form,  does  not  have  the  scissors 
handle,  and  is  of  far  heavier  construction.  The  blades  are  heavy,  and  the 
inner  or  contact  surfaces  are  provided  with  deep  transverse  serrations  hav- 
ing firm  teeth  of  good  size  and  sharp  angles.  A  large  winged  nut,  attached 
to  a  cross-bar  of  good  size,  furnishes  adequate  power  and  supplies  compres- 
sion of  great  force. 


Figure  2176.     Gant's  Clamp. 


Gant's  Clamp,  as  traced  in  figure  2176,  consists  of  two  short  handles 
hinged  at  their  proximal  ends.  The  contact  blades  are  straight,  and  are 
bent  at  a  right  angle  with  the  long  axis  of  the  instrument.  The  blades 


892 


SURGERY    OF    THE    RECTUM. 


expand  by  a  steel  spring,  closure  being  effected  by  a  cross-bar  and  winged 
nut.  The  crushing  surfaces  are  of  the  tongue  and-groove  pattern,  the  pro- 
jecting edge  of  the  former  being  transversely  serrated. 

Cautery. 

Cauterization  may  be  accomplished  either  with  the  thermo-  or  electro- 
cautery,  the  former  being  usually  preferred.  The  form  of  knife  or  point 
is  the  same  as  those  exhibited  in  figure  1134  or  that  shown  in  connection 
with  the  cautery  irlstrument  as  set  forth  in  figure  399. 

Crushing. 

This  may  be  secured  by  clamp,  either  one  of  the  heavier  patterns  of 
those  previously  described,  or  one  specially  constructed  for  the  purpose. 


Figure  21 


Nott's  Clamp,  which  is  shown  in  figure  2177,  is  of  extra-heavy  construc- 
tion, and  has  long  and  slender  handles  terminating  in  T-shaped  jaws,  the 
long  angles  of  which  are  parallel  with  the  handle  line.  The  contact  surfaces 
of  the  jaws  are  of  the  tongue-and-groove  pattern,  the  borders  of  the  grooved 
edge  being  obliquely  serrated  A  cross-bar  and  winged  nut  attached  to 
the  proximal  ends  of  the  handles,  furnish  ample  power. 

Dilatation. 

This  may  be  attempted  by  instruments  with  broad  blades  controlled  by 
screw  power. 


Figure  2178.     Sims'  Dilator. 


Sims'  Dilator,  as  portrayed  in  figure  2178,  has  two  short  well-rounded 
blades  of  bulbous  shape  that  furnish  a  firm  grasping  surface  for  the 
sphincter  ani.  The  handles  are  short,  strong,  and  are  separable  by  a  thumb- 
screw. 


TREATMENT    OF    PROLAPSE. 


893 


TREATMENT   OF  PROLAPSE. 


Radical  Methods. 

Radical  methods  in  the  treatment  of  prolapse  may  consist  of  cauterization 
or  resection.  The  former  consists  in  making  linear  incisions  with  a  cautery 
knife,  employing  one  of  the  curved  variety  as  illustrated  by  figure  1134. 

Resection  will  necessitate  the  use  of  the  minor  operating  instruments 
described  on  pages  270  to  275. 

Palliative  Measures. 

Palliative  measures  may  require  the  use  of  a  supporter,  either  in  the 
form  of  an  internal  plug  or  an  external  truss. 

Prolapsus  Plugs. 

These  are  only  admissible  when  the  sphincter  ani  muscle  still  retains 
a  portion  of  its  contractile  power.  They  consist  of  short  stems  terminating 
in  bulbous  heads. 


Figure  2179.    Olive  Plug.  Figure  2180.     Plain  Pile  Plug. 

The  Olive  Plug,  represented  in  figure  2179,  is  made  from  metal  and  is 
shaped  like  a  flattened  olive.  Usually  they  may  be  purchased  in  sizes  that 
vary  from  i  ^  to  2  inches  in  extreme  length  and  from  to  i  inch  in  breadth. 


Figure  2181.    Trosseau's  Plug. 


Figure  2182.    Prolapsus  Ani  Supporter. 


The  Plain  Plug,  exhibited  in  figure  2180,  is  a  short  cylinder  tapering  at 
its  base,  where  it  is  attached  to  a  round  cross-bar.     They  may  be  procured 


894 


SURGERY    OF    THE    RECTUM. 


in  lengths  that  vary  from  1%  to  2  inches,  while  those  of  different  sizes  may 
readily  be  manufactured  to  order. 

Trousseau's  Plug,  as  traced  in  figure  2181,  consists  of  an  olive-shaped 
support  of  large  size  attached  by  a  slender  stem  to  a  long  oval  base.  Gen- 
erally the  bulb  is  from  i  to  i  %  inches  in  diameter,  the  total  length  of  the 
instrument  being  about  3  inches. 

The  Prolapsus  Ani  Supporter,  set  forth  in  figure  2182,  consists  of  a  waist- 
band with  two  perineal  straps.  Two  curved  steel  springs,  one  with  a 
shorter  curve  than  the  other,  are  dependent  from  the  posterior  portion  of 
the  waist-band.  The  perineal  straps  are  both  attached  to  the  lower  end  of 
the  outer  or  larger  of  these  springs.  The  other  terminates  in  a  hard  pad 
of  firm  material,  so  located  as  to  firmly  contact  the  opening,  serving  to  hold 
the  prolapsed  bowel  in  position.  As  the  straps  are  adjustable,  any  desired 
amount  of  pressure  may  be  obtained. 

TREATMENT  OF  STRICTURE. 

This  may  require  the  use  of  bougies,  sounds  or  dilators. 
Kelly's  Dilator,  as  sketched  in  figure  2183,  is  a  long  rod-like  shaft  pro- 
jecting from  a  handle  bent  downward.     The  shaft  terminates  in  a  screw,  to 


Figure  2183.     Kelly's  Dilator. 

which  dilators  of  various  forms  may  be  attached.  The  latter  consist  of  a 
series  of  slightly  curved  rods,  each  having  a  well-rounded  tip.  They  are 
employed  in  cases  of  rectal  stricture  for  diagnostic  purposes  to  determine  the 
extent  of  the  narrowing,  and  for  purposes  of  dilatation 

REMOVAL  OF  POLYPI. 

Rectal  polypi  may  be  removed  by  forceps,  scissors,  curettes,  etc.,  all  of 
which  should  be  constructed  so  that  they  may  be  used  through  a  speculum. 


Figure  2184.    Kelly's  Cutting  Forceps. 

Kelly's  Cutting  Forceps,  as  traced  in  figure  2184,  consist  of  a  slender 
tubular  shaft  with  scissors  handle  terminating  at  its  distal  end  in  sharp  cut- 
ting jaws.  The  latter  are  actuated  by  the  upper  or  moving  blade,  which, 


TREATMENT    OF    PROLAPSE. 


895 


without  crossing  with  its  mate,  is  attached  by  a  slot  and  shoulder  to  an  inner 
shaft  connected  with  the  upper  or  moving  jaw..  The  jaws  are  slender, 
their  inner  surfaces  grooved,  the  rims  or  borders  being  thin  and  having 
semi-cutting  edges.  They  are  employed  for  removing  rectal  polypi  and 
holding  pledgets  of  cotton  with  which  to  cleanse  the  upper  portion  of  the 
rectum. 


Figure  2185.     Kelly's  Scissors. 

Kelly's  Scissors,  as  portrayed  in  figure  2185,  have  long  shanks,  short 
blades  and  handles  angular-bent  downward,  that  the  hand  of  the  operator 
may  not  obstruct  the  field  of  vision.  The  blades  are  strongly  built,  while 
the  edges  of  the  teeth  are  covered  with  a  series  of  fine  transverse  serrations, 
that  any  grasped  tissues  may  not  be  forced  from  between  the  blades,  when 
the  latter  are  closed.  The  length  of  the  cutting  surfaces  is  about  i  inch 
and  that  of  the  whole  instrument  about  12  inches.  They  will  be  found 
useful  in  the  removal  of  rectal  polypi. 


IMPACTED  FECES. 

When  ordinary  means  fail,  these  may  be  broken  up  and  removed  by  the 
use  of  small  spoon-shaped  instruments   called  scoops. 

ff 


Figure  2186.     Kelly's  Scoop. 

Kelly's  Scoop,  as  depicted  in  figure  2 186,  is  a  long  wire  shaft  with  a  handle 
angular-bent  downward,  its  rectal  end,  shaped  like  a  shallow  spoon,  pro- 
jecting upward  at  an  obtuse  angle  of  about  100°.  The  scoop  portion  of  the 
instrument  is  about  7  millimeters  in  breadth  by  10  in  length.  It  is  gener- 
ally employed  with  a  long  tubular  speculum. 


TRU«X 

Figure  2187.     Plain  Scoop. 


The  Plain  Scoop,  exhibited  in  figure  2187,  is  practically  a  spatula  with 
flattened  blade,  bent  at  an  angle  of  about  130°  with  the  shaft  of  the  instru- 
ment. *  Usually  they  are  flexible,  so  that  they  may  be  curved  to  any  desired 
form. 


CHAPTER  XXXIII. 


PLASTIC  SURGERY. 

This  subject,  so  far  as  it  relates  to  the  construction  and  use  of  special 
instruments,  may  be  confined  to  skin-grafting,  harelip  and  gunpowder  acci- 
dents. 


SKIN-GRAFTING. 

This  operation,  for  artificially  restoring  lost  portions  of  skin,  may  require 
the  following  instruments : 

Minor  operating  list,  see  pages  270  to  275. 
Razor  with  one  edge  flat,  figure  1 6. 
Hooks  for  stretching  skin. 

Razors. 

Razors  suitable  for  this  purpose  do  not  differ  from  those  employed  in 
making  microscopical  sections.  In  skin-grafting  they  are  used  for  removing 
strips  of  the  epidermal  skin  layer.  The  incision  is  best  made  by  a  to-and- 
f ro  sawing  motion,  keeping  the  flat  edge  of  the  razor  parallel  with  the  skin 
surface. 

Hooks  for  Stretching  the  Skin. 

These  are  generally  in  retractor  form  with  blades  recurved  and  provided 
with  fine  short  teeth.  They  are  employed  to  engage  and  draw  the  skin 
tightly  while  it  is  being  incised  with  a  razor  or  other  cutting  instrument. 
They  are  usually  required  in  pairs. 


Figure  2188.     Me  Barney's  Skin  Grafting-Hook. 

McBurney's  Skin-Graf  ting  Hook,  as  pictured  in  figure  21 88,  consists  of  a 
slender  shank  with  fenestrated  handle  and  broad  retractor-like  blade.  The 
latter  is  recurved,  its  outer  margin  being  covered  with  fine  hooked  teeth, 
by  which  a  firm  contact  with  the  skin  may  be  secured.  That  it  may  be 
applied  in  almost  any  position,  the  handle  is  of  sigmoid  shape,  the  blade 
being  on  the  outer  margin  of  the  convex  curve. 


HARELIP. 

Operations  for  harelip  may  be  either  single  or  double,  and  the  instru- 
ments should  include  the  following : 

Scalpel,  or  other  knife,  for  formation  of  flaps,  figures  549  to  597. 

896 


HARELIP. 


897 


Straight  scissors  for  denuding  or  straightening  raw  surfaces,  figure  631. 

Tissue  forceps  for  holding  fine  parts,  figure  604. 

Tenaculuni  for  manipulation  of  flaps,  see  page  1019. 

Harelip  forceps  for  grasping  lip  for  incision. 

Scissors  curved  on  the  flat  with  blunt  points  for  relieving  flap  from 
tension,  figure  635. 

Needles,  sutures  and  dressings. 

Double  harelip  will  require  the  same  list  of  instruments,  but  as  it 
involves  some  disposition  of  the  inter-maxillary  bone,  the  following 
should  be  added : 

Periosteal  elevator  for  removing  the  muco-periosteal  covering  of  the 
bones,  figures  844  to  849. 

Small  retractors  for  holding  flaps  and  periosteum,  figures  616  to  620. 

Strong  scissors  for  removing  sections  of  bone,  figure  634. 


Figure  2189.    Miles'  Harelip  Forceps. 

Miles'  Harelip  Forceps,  as  exhibited  in  figure  2189,  are  straight,  about  7 
inches  in  length,  one  jaw  being  hinged  that  it  may  present  an  even  pressure 
upon  a  flap  that  may  be  thicker  at  one  end  than  at  the  other.  The  fixed 
jaw  has  a  straight  inner  surface,  with  flattened  face;  the  adjustable  jaw 
presents  a  straight,  slender,  flat  base  about  i  y2  inches  in  length.  The  outer 
faces  of  the  handles,  between  the  rings  and  the  lock,  are  transversely  ser- 
rated, that  they  may  furnish  firm  contact  for  a  sliding  link,  with  which  any 
desired  degree  of  compression  may  be  maintained. 


Figure  2190.    Hutchinson's  Harelip  Forceps. 

Hutchinson's  Harelip  Forceps,  as  shown  in  figure  2190,  are  of  the  spring- 
handle  type,  self -opening,  with  T-shaped  jaws,  and  with  shanks  so  curved 
that  the  long  angle  of  the  jaws  is  in  a  line  with  the  handle  of  the  instru- 
ment. The  outer  margins  of  the  jaws  present  a  concave  face.  Compression 
may  be  secured  by  a  cross-bar  provided  with  a  screw  and  nut. 


CHAPTER  XXXIV. 


HERNIA. 

Hernia  may  be  treated  by  either  operative  or  mechanical  methods.  The 
former  will  require  the  minor  operating  instruments  described  on  pages  270 
to  275.  Mechanical  means  consist  in  holding  the  sac  contents,  in  reducible 
cases,  within  the  abdomen.  This  is  effected  by  pressure  on  the  hernial 
opening,  usually  with  some  form  of  truss. 

Trusses. 

Much  has  been  written  regarding  the  supposed  merits  of  such  trusses  as 
are  protected  by  letters  patent.  While  many  such  patterns  have  enjoyed  an 
extensive  sale  and  possess  some  merit,  yet  none  with  which  we  are  familiar 
secures  to  the  wearer  any  advantages  not  found  in  the  ordinary  non-patented 
trusses  of  the  market.  Experience  has  convinced  us  that  the  less  the  num- 
ber of  joints,  parts,  screws,  straps,  etc. ,  in  a  truss,  the  better  it  is,  provided 
it  will  retain  the  hernia;  and,  carrying  the  idea  further,  we  maintain  that  if  a 
hernia  is  reducible  and  can  be  retained  by  a  truss,  this  can  be  accomplished 
as  well  with  a  not-patented  as  with  a  patented  truss.  There  are  few  patients, 
who,  with  care  and  attention,  could  not  be  properly  fitted  with  one  of  the 
plain  designs  ordinarily  found  in  instrument  stores. 

It  is  the  adjustment,  rather  than  the  truss,  that  secures  success.  Often  a 
little  change  in  the  direction  of  pressure  or  the  location  of  the  pad  will  con- 
vert an  imperfect  into  a  perfect  fit.  The  size  and  shape  of  the  pad,  and  the 
amount  of  pressure,  are  also  important  elements,  though  not  so  important 
as  the  two  first  mentioned. 

Trusses  consist  of  a  retention  pad  attached  to  a  steel  spring  or  other  sup- 
port adapted  for  producing  constant  pressure  on  the  hernial  opening.  This 
pressure  should  never  exceed  the  exact  amount  necessary  to  keep  the 
hernia  from  passing  into  the  opening. 

Usually  they  are  formed  with  spring-steel  bands  partially  or  wholly 
encircling  the  hips,  or  with  elastic  bands  that  closely  fit  the  body.  In- 
elastic trusses  of  leather  and  webbing  are  sometimes  used  in  cases  of 
irreducible  hernia.  Bands  of  spring  steel  are  most  commonly  used.  These 
remain  in  place  by  being  formed  in  a  circle  smaller  than  the  body,  so  that 
they  are  "sprung"  into  place,  thus  retaining  their  position  by  their  own 
elasticity.  Such  springs  are  best  when  of  soft  or  partly-tempered  steel, 
for  it  is  usually  necessary,  in  fitting  them,  to  increase  or  decrease  the  amount 
of  pressure.  In  highly-tempered  springs  such  changes  can  not  be  made. 

Steel  springs  are  usually  covered  with  leather,  hard  rubber  or  celluloid. 
The  first  are  called  by  their  true  name,  "leather-covered;"  the  latter,  how- 
ever, are  known  as  "hard  rubber"  and  "celluloid"  trusses,  respectively, 
though  only  a  thin  covering  of  these  materials  overlies  the  steel.  These 
patterns  are  popular,  because  they  can  be  easily  kept  clean,  the  hard  rubber 
wearing  better  than  the  celluloid. 

Two  forms  are  in  common  use,  the  "direct  pressure"  and  the  "cross- 
body. "  In  the  former  the  spring  encircles  the  hip  on  the  same  side  with  the 
hernia,  while  in  the  cross-body  truss  the  spring  encircles  the  opposite  hip. 


TRUSSES.  899 

The  spring  in  the  latter  style  exerts  its  elastic  pressure  on  the  opening 
for  a  longer  proportion  of  its  length,  an  advantage  in  many  cases,  particu- 
larly where  much  pressure  is  necessary.  As  a  rule,  the  springs  only  par- 
tially encircle  the  pelvis,  the  balance  of  the  band  being  completed  by  a 
leather  strap  attached  to  the  terminal  of  the  spring,  its  end  provided  with 
slits  or  perforations  that  may  be  passed  over  a  post  or  button  attached  to 
the  pad. 

Trusses  are  constructed  with  pads  of  material  varying  from  hard  wood, 
hard  rubber  or  ivory,  to  soft  cushions  of  hair  covered  with  thin  soft  leather. 
Others  are  provided  with  spiral  or  other  springs,  while  some  are  composed 
of  a  rubber  sac  filled  with  water  or  glycerine  and  covered  with  silk,  linen 
or  similar  fabric.  In  shape  the  pads  are  of  all  possible  forms  and  sizes,  so 
that  almost  any  combination  may  be  secured.  They  vary  in  form  from 
sharply  convex  to  shallow  concave,  the  former  pressing  upon  or  into  the 
opening,  the  latter  around  it.  In  many  forms  of  trusses  the  spring  and  pads 
are  continuous,  as  in  figure  2191,  while  in  others  the  pad  is  attached  to  a 
connecting  shank,  as  represented  in  figure  2195.  Those  made  on  the  first- 
mentioned  plan  can  not  be  reversed,  and  can  only  be  worn  upon  the  side  for 
which  they  are  manufactured.  Nearly  all  of  the  patterns  provided  with 
shanks  are  pivoted,  so  that  they  can  be  used  upon  either  side.  Others  are 
constructed  with  ball-and-socket  joints,  not  only  at  the  attachment  of  the 
pad  to  the  shank,  but  at  the  point  at  which  the  latter  joins  the  spring,  thus 
affording  an  almost  limitless  range  of  movement. 

Various  degrees  of  spring  force  are  necessary ;  if  too  little,  the  hernia  is 
not  retained  under  severe  strain ;  if  too  great,  the  instrument  causes  pain 
and  often  can  not  be  worn. 

Elastic  trusses  are  composed  of  rubber  webbing,  to  which  suitable  pads 
are  attached.  They  fit  closely  to  the  body,  do  not  interfere  with  the  cloth- 
ing, and  are  preferred  by  some  patients.  As  a  rule,  they  are  not  as  efficient 
as  spring  trusses,  because  the  pressure  can  not  be  varied ;  neither  can  the 
direction  of  pressure  be  changed  to  any  great  extent. 

Further  than  this,  while  not  absolutely  safe  in  all  cases,  they  are  objec- 
tionable because  they  readily  absorb  perspiration  and  skin  secretions.  The 
ever-present  perineal  band  of  this  truss  is  also  a  source  of  annoyance  to 
many  patients,  especially  in  warm  weather. 

Trusses  are  either  single  or  double,  depending  on  whether  arranged  for 
retaining  hernia  upon  one  or  both  sides.  Occasionally,  when  the  abdominal 
wall  on  the  side  opposite  the  rupture  is  thought  to  be  weak,  double  trusses 
are  prescribed. 

Generally,  almost  any  plain  truss  is  applicable  to  hernia  in  children,  prob- 
ably the  best  being  the  French  model  covered  with  soft  rubber  As  these 
do  not  absorb  urine  or  other  fluids,  they  are  particularly  adapted  for  use  on 
infants. 

This  department  of  surgery  is  one  that  can  ordinarily  be  safely  entrusted 
to  the  instrument  maker,  for  many  of  the  latter  are  expert  truss  fitters,  a 
science  that  surgeons,  as  a  rule,  know  little  about. 

Two  points,  however,  should  not  be  overlooked  by  the  practitioner:  First, 
Is  the  case  one  of  hernia  beyond  a  doubt?  Second:  If  so,  is  it  reducible? 

The  instrument  maker  should  not  be  expected  to  diagnose  a  case  under 
treatment.  We  have  known  many  patients  with  hydrocele,  varicocele,  in- 
flamed and  undescended  testes,  and  irreducible  hernia  who  have  been  ordered 
to  dealers  for  trusses.  The  instrument  maker  is  often  obliged  to  request 
patients  to  return  to  their  surgeon,  either  because  the  case  is  irreducible  or 


900  HERNIA. 

is  not  hernia.  It  is  advisable  for  the  surgeon  to  inspect  a  case  after  a  truss 
has  been  fitted,  as  this  ensures  to  the  patient  a  perfect  and  properly-fitting 
instrument. 

A  truss  should  not  only  be  efficient  but  should  feel  as  comfortable  as  a 
glove  or  a  shoe ;  it  should  always  be  fitted  with  the  patient  in  a  recumbent 
position,  and  should  be  worn  at  night  if  the  rupture  descends  during  that 
time.  Patients  should  not  only  be  instructed  how  to  fit  and  adjust  their 
trusses  to  themselves,  but  how  to  return  the  hernias  to  place. 

Trusses  as  ordinarily  purchased  require  to  be  more  or  less  changed,  both 
in  shape  and  in  the  power  exerted  by  the  spring,  before  a  perfect  fit  is 
secured.  As  persons  are  seldom  of  the  same  contour  in  a  line  with  the 
hernia,  it  is  only  occasionally  that  a  truss,  as  it  comes  from  the  manufac- 
turer, will  accurately  fit  a  given  case.  As  a  rule,  patients  who  experience  dis- 
comfort and  torture  because  of  a  truss,  are  those  who  purchase  one  from 
the  druggist  or  dealer  without  reference  to  its  adaptability  to  their  case, 
and  who  apply  and  use  the  instrument  without  making  the  necessary 
changes  in  its  form  and  shape. 

Leather-covered  trusses  may  be  curved  and  shaped  with  the  hands  until 
proper  adjustment  is  secured.  The  surgeon  receiving  a  truss  of  this  char- 
acter need  not  hesitate  to  make  such  forcible  alterations  as  the  case  may 
require,  for  if  the  spring  is  broken  during  such  treatment,  the  dealer  should 
replace  it  without  extra  charge.  Trusses  covered  with  hard  rubber  and 
similar  material  should  not  be  changed  in  shape  until  they  have  been 
warmed  by  holding  them  over  a  stove  or  register,  dipping  them  in  hot  water 
or  a  similar  procedure.  An  attempt  to  change  the  shape  of  a  hard- rubber- 
covered  truss  when  of  ordinary  temperature  may  result  in  cracking  or  split- 
ting off  pieces  of  the  rubber  with  which  the  truss  is  covered. 

The  common  forms  of  hernia  requiring  the  use  of  trusses,  are  in- 
guinal, femoral,  umbilical  and  ventral,  according  to  the  location  of  the 
opening. 

Inguinal  Hernia. 

Inguinal  hernia,  often  called  scrotal,  whether  oblique  or  direct,  may 
be  successfully  treated  with  a  truss.  In  cases  of  oblique  descent,  long  and 
somewhat  pear-shaped  pads  are  generally  preferred.  Those  with  convex 
inner  surfaces  are  usually  selected,  and,  when  the  abdomen  is  inclined  to 


Figure  2191.    Plain  French  Truss.  Figure  2192.    Improved  Scrotal  Truss. 


be  pendulous,  the  lower  border  of  the  truss  should  point  somewhat  upward 
as  well  as  inward,  resting  on  the  internal  ring  and  inguinal  canal,  not 
against,  but  close  to,  the  pubic  arch.  In  congenital  cases  a  long  slender 
pad  is  necessary,  one  that  is  elongated  downward  between  the  scrotum  and 
the  thigh,  and  tapers  gradually  to  a  strap. 

The  Plain  French  Truss,  exhibited  in  figure  2191,  is  without  joints  or 


FEMORAL    HERNIA    TRUSSES. 


901 


other  mechanism.  It  consists  of  a  plain  pad  riveted  to  an  ordinary  steel 
truss  spring.  The  latter  is  covered  with  soft  leather,  while  the  pad  is  cush- 
ioned with  hair  or  other  elastic  material.  As  this  pattern  is  not  reversible, 
it  is  necessary  to  procure  one  for  the  right  or  left  side,  according  to  the 
location  of  the  hernia. 

The  Improved  Scrotal  Truss,  set  forth  in  figure  2192,  consists  of  along 
pear-shaped  pad  slightly  curved  on  the  edge  and  attached  to  a  steel  spring 
in  such  a  manner  that  the  lower  border  of  the  truss  may  be  carried  outward 
or  inward  as  the  case  may  demand.  To  secure  this,  the  shank  that  con- 
nects the  pad  with  the  spring  is  elongated,  its  outer  border  slotted  in  such 
a  manner  as  to  receive  a  screw  by  which  fixation  at  any  desired  point  is 
secured.  This  pattern,  like  the  preceding,  is  applicable  to  only  one  side. 


Figure  2193.    Champion  Truss. 


Figure  2194.     Cross  Body  Truss. 


The  Champion  Truss,  exhibited  in  figure  2193,  contains  as  its  principal 
feature  a  pad  and  shank  that  are  not  only  reversible,  but  that  may  be  placed 
in  any  desired  shape  or  position.  The  pad  is  attached  to  the  shank  and  the 
spring  by  universal  joints.  After  each  is  placed  in  the  desired  relation  with 
the  other,  fixation  may  be  secured  by  a  thumb  and  finger  nut. 

The  Cross-Body  Truss,  displayed  in  figure  2194,  differs  from  the  patterns 
previously  described  in  that  the  spring  encircles  the  hip  opposite  to  the 
side  upon  which  the  rupture  occurs.  This  of  course  applies  only  to  single 
trusses.  As  a  rule,  the  pads  are  so  attached  to  the  spring  that  any  direction 
of  pressure  may  be  obtained. 

Femoral  Hernia. 

Femoral  hernia,  while  it  may  frequently  be  treated  with  one  of  the 
trusses  previously  mentioned,  usually  requires  one  with  a  long  and  some- 
what slender  neck,  terminating  in  a  pad  that  will  exert  pressure  upon  a 
limited  space  only. 


Figure  2195.    Chase's  Femoral  Truss. 


Figure  2196.    Chase's  Extension  Truss  with 
Water  Pad. 


Chase's  Femoral  Truss,  as  depicted  in  figure  2195,  consists  of  a  plain 
steel  spring  and  malleable  shank,  and  a  small  hard  ovoid  pad  having  a  con- 
vex contact  surface.  These  patterns  are  usually  of  light  construction,  are 
easily  adjusted  and  furnish  a  comfortable  support. 

COLLUGE   0 


902 


HERNIA. 


Chase's  Extension  Truss  with  Water  Pad,  as  portrayed  in  figure  2196, 
differs  from  the  pattern  last  described  in  that  the  pad  is  attached  to  a  shank 
by  a  slot  device  by  which  the  shank  may  be  lengthened  or  shortened  as 
desired.  While  this  pattern  may  be  secured  with  any  form  of  pad,  it  is 
here  shown  with  a  water  pad.  The  latter,  though  more  often  filled  with 
glycerine,  consists  of  a  soft  rubber  bag  of  proper  shape  and  firm  texture, 
covered  with  some  fabric,  silk  being  usually  selected.  It  is  claimed  that 
this  form  of  pad  is  both  firm  and  elastic,  and  that  it  furnishes  ample  support 
without  heating  or  irritating  the  skin. 


Figure  2197.    New  York  Elastic  Truss. 


Figure  2198.    Chase's  Double  Truss,  Covered 
with  Hard  Rubber. 


The  New  York  Elastic  Truss,  represented  in  figure  2197,  consists  of  a 
pad  plate  covered  with  leather  or  firm  cloth  and  held  in  place  by  a  band  of 
elastic  webbing,  the  latter  firmly  secured  to  the  hips  by  a  strap  and  buckle. 
This  pattern  is  constructed  with  a  perineal  band  by  which  it  is  held  in 
proper  position. 

Chase's  Double  Truss,  as  outlined  in  figure  2198,  does  not  differ  in  gen- 


eral construction  from  the  Chase  pattern  previously  described, 
duced  to  show  the  general  form  of  double  truss. 

Umbilical  Hernia. 


It  is  intro- 


Umbilical  hernia  may  be  successfully  treated  by  trusses  of  plain  con- 
struction. A  large  oval  pad  with  a  small  cone-shaped  protuberance  in  its 
center,  held  in  place  by  a  bandage  of  some  firm  fabric  or  a  steel  elliptical 
spring,  will  meet  every  requirement. 


Figure  2199.     Elastic  Umbilical  Truss. 


Figure  2200.    Bow-Spring  Umbilical  Truss. 

The  Elastic  Umbilical  Truss,  displayed  in  figure  2199,  consists  of  a  large 
oval  pad  attached  by  straps  to  a  wide  belt  that  encircles  the  trunk.  The 
pads  are  usually  leather-covered  and  provided  in  the  center  with  a  small 
cone  intended  to  cover  the  point  of  exit  of  the  hernia.  As  this  pattern 
meets  every  requirement  as  a  retention  apparatus,  fits  the  body  closely  and 
can  be  worn  with  comfort,  it  is  generally  preferred. 

The  Bow-Spring  Umbilical  Truss,  as  represented  in  figure  2200,  consists 
of  an  elliptical  spring  to  the  convex  surface  of  which  an  oval  pad  is  attached. 
By  strap  pressure  applied  to  the  tips  of  the  spring,  the  convex  is  changed  to 


UMBILICAL    AND    VENTRAL    HERNIA    TRUSSES. 


903 


a  concave  surface,  thus  furnishing  a  support  in  proportion  to  the  strength 
and  convexity  of  the  applied  spring. 

The  Soft  Rubber  Umbilical  Truss,  exhibited  in  figure  2202,  con- 
sists of  a  soft  rubber  band  provided  with  eyelets  and  a  lacing  string  by 
which  proper  adjustment  is  secured.  The  anterior  inner  surface  of  the 


Figure  2201.    Infant's  Single  Truss 
Covered  with  Soft  Rubber. 


Figure  2202.    Infant's  Soft 

Rubber  Umbilical 

Truss. 


Figure  2303.    Infant's  Double  Truss 
Covered  with  Soft  Rubber. 


truss  is  provided  with  a  conical  bag  into  which  air  or  water  may  be  injected 
to  give  the  sac  proper  shape  and  firmness.  They  are  advised  for  children, 
not  only  because  they  are  efficient,  but  for  the  reason  that  the  material  is 
not  affected  by  urine  or  other  fluids. 

The  Soft  Rubber-Covered  Trusses,  displayed  in  figures  2201  and  2203,  are 
of  the  ordinary  French  pattern  differing  from  those  previously  described  in 
being  covered  with  soft  rubber.  This  material  is  not  only  non- irritating  but 
does  not  absorb  fluids.  For  this  reason  these  patterns  are  particularly 
advised  for  use  on  infants. 

Ventral  Hernia. 

Ventral  hernia  may  usually  be  treated  by  some  one  of  the  patterns  of 
trusses  previously  described,  the  one  selected  depending  on  the  location 
of  the  rupture.  In  special  cases  it  may  be  necessary  to  have  a  truss  manu- 
factured, in  which  event  an  instrument  maker  should  be  consulted. 

Abdominal  supports  with  firm  pads  over  the  site  of  rupture  are  often 
employed  with  satisfaction. 


CHAPTER  XXXV. 


MILITARY  SURGERY. 

This  subject,  as  far  as  it  comes  within  the  scope  of  this  work,  will  include 
only  descriptions  and  illustrations  of  such  appliances  as  are  particularly 
adapted  for  army  medical  use.  This  comprises  apparatus  for  primary 
dressings ;  pouches  and  their  contents,  for  the  use  of  orderlies  and  mem- 
bers of  the  hospital  corps;  field  and  hospital  operating  cases;  medical  and 
surgical  chests  for  field  and  permanent  hospital  use,  and  means  for  the 
transportation  of  the  sick  and  wounded. 


FIRST  AID    PACKAGES. 

These  contain  various  articles  necessary  for  the  dressing  of  wounds  in 
emergency  cases.  They  are  intended  for  the  individual  use  of  the  soldier 
to  be  applied  by  himself  or  a  comrade  in  cases  where  he  can  not  receive 
immediate  attention  from  a  surgeon.  They  are  also  largely  employed  in 
factories,  machine  shops,  in  railroad  emergency  chests  and  police  depart- 
ments. 


FIRST  HELP 

FOR  WOUNDED 

CONTENTS 


Figure  2304.    Esmarch's  First 
Help  for  Wounds. 


Figure  2205.    Senn's  Antiseptic  Tampon  Package. 


Esmarch's  First  Help  for  Wounds  (so  named  by  its  author),  as  exhibited 
in  figure  2204,  contains: 

2  Antiseptic  Compresses  of  gauze,  each  wrapped  in  oil  paper. 

i  Antiseptic  Bandage  of  muslin  with  safety-pin. 

i  Antiseptic  Esmarch's  Triangular  Bandage  with  safety-pin.  Accom- 
panied by  the  following  directions: 

"Place  one  of  the  compresses  on  the  wound  after  removing  the  oil 
paper.  In  cases  of  large  wounds,  open  the  compress  and  cover  the  whole 
wound.  Apply  the  bandage  over  the  compress,  then  use  the  triangular 
bandage  as  shown  by  the  illustration  found  printed  on  same.  " 

The  compresses  consist  of  strips  of  antiseptic  gauze  3^  inches  wide  and 
i  yard  long.  These  are  folded  into  packages  2  inches  wide  and  3%  inches 

904 


FIRST    AID    PACKAGES.  905 

long.  The  roller  bandages  are  usually  4  inches  wide  and  2  yards  long 
folded  flat,  while  the  triangular  bandage  is  of  the  Esmarch  pattern  as  illus- 
trated in  figure  799.  The  package  is  covered  with  water-proof  rubber 
upon  which  the  directions  are  printed,  and  so  folded  that,  if  properly  ster- 
ilized, it  may  be  kept  free  from  infection  for  an  indefinite  period. 

Senn's  Antiseptic  Tampon  Package,  as  illustrated  in  figure  2205,  is 
intended  to  be  sewed  to  the  inner  surface  of  the  cartridge  belt  in  the  center 
of  the  back.  It  is  claimed  by  Senn  that,  because  this  belt  would  be  one  of 
the  last  articles  a  soldier  would  part  with  in  case  of  engagement,  if  wounded 
or  injured,  the  tampon  package  would  be  found  upon  his  person.  The 
package  consists  of  2  grains  of  boric  and  y2  a  grain  of  salicylic  acid  thor- 
oughly triturated  together  and  incorporated  in  the  center  of  a  2  dram  flat 
compressed  package  of  absorbent  cotton.  This  cotton  is  surrounded  by  a 
triangular  gauze  bandage  as  exhibited  in  figure  799,  the  whole  including  a 
safety-pin,  covered  by  a  wrapper  of  gutta-percha.  In  applying  the  dressing, 
the  compressed  cotton  is  loosened,  the  wound  freely  dusted  with  the  powder 
contained  in  the  center  of  the  package,  the  wound  well  covered  with  the 
cotton  which  should  overlap  its  margins,  and  the  dressing  held  in  place  by 
the  triangular  bandage  and  such  additional  extemporized  means  of  reten- 
tion as  may  be  necessary.  This  package  is  much  smaller  and  lighter 
than  the  one  advised  by  Esmarch  though  it  contains  all  the  articles  neces- 
sary in  a  temporary  antiseptic  occlusion  compress. 

While  particularly  recommended  for  military  use,  this  package  forms  a 
desirable  requisite  for  surgeons  generally. 

Erwin's  First  Aid  Package  contains  one  roll  of  3-inch  bandage,  6  yards  in 
length,  an  antiseptic  gauze  compress  and  an  aseptic  probe  enclosed  in  a 
small  roll  of  antiseptic  gauze,  together  with  a  safety-pin.  The  second  roll 
of  antiseptic  gauze  is  large  enough  to  form  a  compress.  Each  roll  and  com- 
press is  wrapped  in  paraffin  paper  and  the  whole  enclosed  in  an  aseptic 
rubber  cover,  hermetically  sealed  so  that  it  is  impregnable  to  moisture  and 
atmospheric  influences.  The  whole  is  included  in  a  duck  pouch  perma- 
nently attached  to  the  belt  from  which  it  should  never  be  removed  except 
for  dressing  purposes,  or  when  necessary  to  be  replaced  by  a  fresh  one. 

POUCHES. 

Pouches  for  the  use  of  the  Medical  Department  of  the  Army  consist  of 
bags  or  sacks  manufactured  from  heavy  ducking  and  provided  with  straps 
for  carrying  over  the  shoulder.  Those  in  use  by  the  United  States  Army 
are  of  two  varieties,  one  to  be  carried  by  each  member  of  the  hospital  corps, 
the  other  by  the  surgeon's  orderly. 

The  Hospital  Corps  Pouch  exhibited  in  figure  2207  contains: 

60  c.c.  Aromatic  Spirits  of  Ammonia  in  a  Leather-covered  Pocket  Flask 
with  Cup. 

i  Case  Containing  Common  and  Safety-Pins,  Scissors  and  Dressing 
Forceps. 

6  First  Aid  Packages. 

i  Pocket  Knife  with  Saw  Blade. 

i  Rubber  Bandage. 

i  Roll  Wire  Gauze  for  Splints. 

i  Spool  Rubber  Adhesive  Plaster. 

The  above  is  contained  in  a  leather-trimmed  duck  pouch  with  double 
walls,  and  with  buckle  and  shoulder  strap. 


906 


MILITARY    SURGERY. 


The  Orderly's  Pouch,  though  similar  in  construction  to  that  employed  by 
the  hospital  corps,  is  of  larger  size  and  contains  the  following : 

60  c.c.  Aromatic  Spirits  of  Ammonia  in  Leather-covered  Pocket  Flask 
with  Cup. 

i  Bottle  Antiseptic  Tablets. 

6  Roller  Bandages. 

i  Pocket  Case  of  Instruments. 


Figure  2207.    Hospital  Corps  Pouch. 


ioo  Grammes  Chloroform  in  Protected  Bottle, 
i  Rubber  Catheter  in  Metal  Box. 

1  Box  Diagnostic  Tags  and  Pencil. 
4  First  Aid  Packages. 

2  Yards  Antiseptic  Gauze  (Sterilized)  in  ^-yard  packages 
i  Pocket  Knife  with  Saw  Blade. 

i  Bottle  Assorted  Catgut  Ligatures. 
30  c.c.  Chloroform  and  Opium  Mixture, 
i   Paper  Pins, 
i  Paper  Safety- Pins, 
i  Rubber  Tourniquet, 
i  Scissors. 

i  Roll  Wire  Gauze  for  Splints, 
i  Spool  Rubber  Adhesive  Plaster, 
i  Hypodermic  Syringe, 
i  Metal  Tray  in  which  to  Boil  Instruments. 
The  Pocket  Case  contains : 

i  Curved  Sharp- Pointed  Bistoury, 
i  Probe- Pointed  Bistoury, 
i  Straight  Bistoury. 


FIELD  AND  HOSPITAL  OPERATING  CASES. 


907 


i  Catheter,  Jointed,  Male  and  Female. 

i  Caustic  Holder. 

i  Hemostatic  Forceps  and  Needle  Holder. 

i  Hemostatic  Forceps. 

i*  Dressing  Forceps. 

i  Aneurysm  Ligature  Carrier  and  Director. 

i  Exploring  Needle. 

i  Nelaton's  Probe. 

i  Silver  Probe. 

i  Scalpel. 

i  Scissors. 

i  Tenaculum. 

i  Tenotome. 

With  silk,  needles,  silver  wire,  wax  and  silkworm  gut  ligatures.  The 
bandages  and  gauze  should  be  sterilized,  wrapped  in  oiled  paper,  and 
coated  with  stearine  or  a  similar  substance. 


[Sterilized  Gauze. 
^«,7f£Fi^> 
ICtiasTruaxGreene&G'l 

•75477WabashAve 

CHiC  ASO.ILL 


Figure  2208.    Sterilized  Roller  Bandage  for  Army  Use.    Figure  2209.    Sterilized  Absorbent  Gauze 

for  Army  Use. 

The  Pocket  Knife  with  Saw  Blade,  exhibited  in  figure  2210,  is  of  heavy 
construction  with  cutting  and  saw  blades  each  4  inches  in  length.  This 
will  be  found  useful  not  only  in  the  manufacture  of  splints  but  in  the  per- 
formance of  the  general  duties  connected  with  the  care  of  the  sick  in  camp 
life. 


TRUftX-GFEENF-C:. 


Figure  3210.     Pocket  Knife  with  Saw  Blade. 


Figure  2211.    Roll  of  Wire  Gauze 
for  Splints. 


The  Roll  of  Wire  Gauze  for  Splints,  displayed  in  figure  2211,  is  a  strip  6 
inches  wide  and  i  yard  in  length  compactly  rolled  and  bound  with  copper 
wire  that  it  may  occupy  a  limited  space.  It  may  be  cut  to  any  desired  size 
with  a  heavy  knife  blade  or  shears. 


FIELD  AND  HOSPITAL  OPERATING  CASES. 

The  general  adoption  of  the  principles  governing  aseptic  surgery  have 
not  only  resulted  in  many  changes  in  the  construction  of  surgical  instru- 
ments, but  in  the  arrangement  of  means  employed  for  storing  and  trans- 
portation. 


908 


MILITARY    SURGERY. 


In  military,  as  in  general  surgery,  only  such  cases  should  be  selected  for 
surgical  instruments  as  will  allow  not  only  complete  sterilization  in  every 
part,  but  the  addition  of  such  instruments  as  may,  from  time  to  time,  be 
deemed  essential. 

The  necessity  for  improvement  in  this  direction  became  quite  evident  at 
the  opening  of  the  recent  war  with  Spain,  and  while  the  time  for  devising 
and  constructing  improved  patterns  was  limited,  we  believe  a  considerable 
advance  was  made. 

Stimulated  by  an  urgent  request  from  Terry,  then  Surgeon  General  of 
New  York,  who  demanded  for  the  troops  of  his  state  an  improved  equip- 
ment, the  author  sought  the  advice  of  Senn,  who  holds  a  similar  position  in 
the  State  of  Illinois.  A  set  of  instruments  was  advised  by  the  latter,  a  case 
prepared  and  submitted  to  Terry,  who  pronounced  the  selection  of  instru- 
ments admirable,  but  the  container,  while  an  improvement  over  previous 
patterns,  still  unsatisfactory.  After  extended  consultations  with  both  of 
these  surgeons,  a  case  was  produced  with  which  the  New  York  regiments 
were  equipped.  Its  adaptability  for  field  work  commended  it  to  the  atten- 
tion of  the  surgeon  generals  of  other  States,  so  that  many  regiments,  prom- 
inent among  which  were  those  from  Ohio,  were  equipped  with  similar 
outfits. 


Figure  2212.     Terry's-Senn's  Field  Operating  Case. 

Terry's  Modification  of  Senn's  Field  Operating  Case,  as  defined  in  figure 
2212,  comprises  such  instruments  as  are  deemed  essential  for  emergency 
use  on  the  field  of  battle.  The  instruments,  inclusive  of  needles,  are  32  in 
number  and  are  contained  in  a  washable  roll-up  pouch.  This  is  protected 


MEDICAL  AND  SURGICAL  CHESTS. 


909 


by  two  telescoping  trays,  either  of  which  may  be  used  for  sterilizing  pur- 
poses. The  smaller  or  lower  is  provided  with  folding  legs  and  handles,  so 
that  it  may  be  employed  as  an  instrument  boiler.  The  whole  is  enclosed 
in  a  patent-leather  pouch  with  strap  for  carrying  over  the  shoulder.  The 
assortment  of  instruments  is  given  in  detail  on  page  409. 


MEDICAL  AND  SURGICAL  CHESTS. 

The  construction  of  medical  and  surgical  chests  for  military  use  has 
occupied  the  attention  of  many  of  the  ablest  surgeons  in  all  times  ever  since 
the  practice  of  medicine  became  an  art.  To  provide  in  a  compact  and 
portable  form  the  necessary  means  for  treating  the  diseased  and  injured  is 
a  problem  that  to-day  confronts  the  army  medical  corps  of  all  nations.  In 
this  department  the  United  States  authorities  have  kept  pace  with,  even  if 
they  are  not  in  the  lead  of,  other  nations.  The  large,  and  we  may  say,  cum- 
bersome regimental  outfits  supplied  to  the  British,  French,  German  and 
Russian  armies  are  replaced  in  the  United  States  service  with  small,  com- 
pact chests  that  are  easy  to  handle  and  convenient  to  use.  They  are  sup- 
plied in  pairs.  Primarily  they  were  adopted  that  they  might  be  carried  by 
horse  or  mule,  and  latterly  retained  in  this  form  because  each  is  of  a  weight 
easily  managed,  while  the  two  resting  end-to-end  fill  the  space  beneath  the 


Figure  2213.    Senn's  Army  Medical  and  Surgical  Chest. 

•driver's  seat  in  the  standard  army  ambulance.  The  Medical  Chest  contains 
large  quantities  of  compressed  tablets,  while  in  the  drawers  and  their  com- 
partments are  arranged  the  various  appliances  deemed  necessary.  The 
Surgical  Chest,  in  addition  to  the  various  instruments  and  dressings,  contains 
such  drugs  as  can  not  be  placed  in  the  Medical  Chest.  The  boxes  are  of 
wood  with  dovetailed  corners  and  brass  trimmings,  the  two  weighing  185 
pounds. 

Senn's  Army  Medical  and  Surgical  Chest.  Colonel  N.  Senn,  when  ap- 
pointed Surgeon  General  of  Illinois,  wishing  to  equip  the  regiments  under 
his  charge  with  modern  outfits,  devised  a  single  chest  smaller  than  either 


910 


MILITARY    SURGERY. 


of  the  two  employed  by  the  Government,  into  which  by  a  system  of  close 
packing  he  succeeded  in  placing  a  large  list  of  surgical  and  medical  neces- 
sities. The  glass  tablet  bottles  of  the  United  States  army  pattern  were 
replaced  with  slide  aluminum  boxes,  as  exhibited  in  figure  2214. 

Many  of  the  glass  bottles  for  liquids  were  replaced  with  those  spun 
from  aluminum,  as  portrayed  in  figure  288.  In  the  manufacture  and 
selection  of  each  article  every  provision  was  made  to  secure  compactness, 
not  only  in  the  article  itself  but  in  its  arrangement  in  the  case.  To  facil- 
itate the  latter  and  to  prevent  confusion  of  articles,  nine  compartment 
boxes,  each  with  a  cover  and  handle,  and  numbered  consecutively  are  ar- 
ranged to  rest  on  end,  as  shown  in  the  illustration.  By  mismatching  the 


Figure  2214.    Author's  Slide  Aluminum  Box  for  Army  Medical  Use. 

joints,  any  one  may  be  removed  without  displacing  the  balance.  The  chest 
itself  is  of  aluminum  with  triple  wall.  The  latter  consists  of  a  double  sheet 
of  aluminum  between  which  a  board  of  leatherine  is  securely  fastened.  The 
frame  itself  is  of  untempered  angle  steel  with  joints  firmly  riveted.  As 
seen  by  the  illustration  in  figure  2213,  the  cover  is  hinged,  and  when  opened 
up,  displays  on  its  under  surface  an  alphabetical  list  of  contents.  Opposite 
each  article  is  printed  the  number  of  the  compartment  box  in  which  it  may 
be  found.  The  list  of  contents  varies  somewhat  from  the  United  States 
army  pattern,  but  while  seemingly  as  complete,  it  is  all  contained  within 
a  chest  that  in  external  measurements  is  12^  by  12^  by  19  inches  and 
weighs  only  76  pounds. 

The  New  York  Medical  Chest,  exhibited  in  figure  2215,  is  a  compromise 
between  the  compact  pattern  of  Senn  and  the  two  chests  employed  in  the 
regular  army. 

It  consists  of  a  single  box  constructed  of  angle  steel  with  aluminum 
sides  and  partitions,  but  with  both  top  and  front  side  hinged  the  same  as  the 
army  pattern.  The  compartment  boxes  of  Senn  are  replaced  with  an  open 
tray  with  partitions  that  fill  the  top  of  the  chest  and  in  which  the  gauze, 
cotton,  first-aid  packages,  large  bottles  and  many  of  the  larger  articles  are 
stored.  It  is  claimed  that  being  within  ready  reach,  this  is  an  advantage. 
The  smaller  articles,  including  the  instruments,  are  arranged  in  five  drawers 
placed  underneath  the  tray.  The  compressed  tablets  are  contained  in 
square  hard  rubber  bottles.  This  system  avoids  the  seeming  error  in  the 
construction  of  the  Government  outfits,  for  in  the  latter  the  tablets  are  not 
only  placed  in  glass  bottles  but  each  bottle  is  surrounded  by  a  wooden  par- 
tition and  each  set  of  partitions  enclosed  in  a  drawer,  and  each  drawer 
mounted  in  a  frame.  In  this  system,  measuring  the  cubic  inches  enclosed 


MEDICAL  AND  SURGICAL  CHESTS. 


911 


within  the  outside  of  the  drawer  frame  and  comparing  with  that  the  net 
bulk  of  all  the  enclosed  tablets,  it  will  be  found  that  the  percentage  of  lost 
space  is  great.  By  employing  the  system  exhibited  in  the  New  York  chest 


Figure  2215.    New  York  Array  Medical  and  Surgical  Chest,  Open. 

it  will  be  found  that  not  only  are  the  walls  of  the  bottles  thin,  but  that  they 
may  be  safely  placed  one  against  the  other  without  intervening  partitions, 
and  that  they  may  be  enclosed  with  a  single  sheet  of  aluminum.  As  these 


Figure  2316.    New  York  Army  Medical  and  Surgical  Chest,  Closed. 

bottles  are  practically  water-tight,  it  would  seem  that  the  system  offers  an 
ideal  method  for  the  transportation  of  tablets,  powders,  etc.  The  name 
of  the  article  may  be  stamped  in  the  cork  and  the  imprint  filled  with 
white  lead,  thus  furnishing  a  white  and  lasting  letter  on  a  black  background. 


912  MILITARY    SURGERY. 

Bottles  of  similar  material  are  provided  for  such  liquids  as  may  be  safely 
stored  in  hard  rubber  receptacles. 

A  second  new  departure  in  the  arrangement  of  this  chest  is  the  subdi- 
vision of  the  absorbent  cotton,  antiseptic  gauze  and  jute  into  small  pack- 
ages for  individual  use.  The  cotton  is  in  ounce  packages,  the  gauze  in 
half-yards  and  the  jute  in  4-ounce  packages.  These  articles  are  sterilized, 
enclosed  in  double  wrappers  of  oiled  paper  and  each  package  sealed  by 
immersion  in  melted  paraffin.  This  furnishes  antiseptic  dressings  that  will 
keep  indefinitely  without  risk  of  contamination. 

The  chest  itself  is  strongly  reinforced  by  spread  braces  that  extend  from 
the  center  of  each  side  frame  to  the  four  corners  that  occupy  the  same  plane, 
the  whole  framework  being  strongly  riveted  together.  Circle  stops  hold 
the  top  and  front  side  when  extended  in  proper  position.  Strong  steel 
straps  extending  around  the  case  assist  in  holding  the  sides  firmly  in  place. 
The  whole  is  covered  with  sole  leather  securely  fastened  with  straps  and 
buckles.  This  case  was  devised  and  arranged  by  a  committee  of  three  sur- 
geons appointed'  by  Surgeon  General  Terry,  consisting  of  Major  W.  E. 
Lambert  of  the  i2th  Regiment,  N.  G.  N.  Y.,  Major  Bennett  S.  Beach  of  the 
22nd  Regiment,  N.  G.  N.  Y.  and  Major  John  Van  R.  Hoff,  U.  S.  A. 


TRANSPORTATION  OP  THE  SICK  AND  WOUNDED. 

This  subject  is  one  that  in  late  years  appears  to  have  been  successfully 
considered,  for  it  would  seem  that  nothing  more  could  be  provided  that 
would  insure  greater  comfort  to  the  sick  or  injured  either  while  in  camp, 
on  the  march,  or  the  battle-field,  than  the  appliances  of  to-day.  The  vari- 
ous forms  of  apparatus  consist  of  stretchers,  litters  and  ambulances  and 
the  appliances  for  hospital  are  described  on  pages  83  to  87. 

Stretchers. 

These  consist  of  a  portable  bed  or  cot,  light  in  construction,  folding  for 
convenience  in  transportation  and  of  a  strength  sufficient  to  maintain  a 
weight  of  about  300  pounds. 

The  United  States  Army  Stretcher,  pattern  of  1895,  as  exhibited  in  fig- 
ures 2217,  2218  and  2219,  is  perhaps  the  best  appliance  of  its  kind  in  exist- 
ence. It  is  plain  in  design,  strong  in  construction,  compact  in  arrange- 
ment, and  easily  carried  when  in  service.  It  is  the  result  of  extensive 
research  and  many  experiments  on  the  part  of  the  regular  Army  Medi- 
cal Staff.  Colonel  C.  H.  Alden,  Assistant  Surgeon  General,  U.  S.  A., 
under  whose  directions  it  was  perfected,  probably  contributed  more  toward 
securing  an  ideal  appliance  than  any  other  officer.  While  the  arrange- 
ment furnishes  as  efficient  and  durable  a  pattern  as  those  previously  em- 
ployed, the  weight  is  reduced  from  26  to  20  pounds.  It  is  more  simple  in 
its  arrangement  than  the  older  designs,  and  will  sustain  an  equal  weight, 
while  its  mechanism  is  reduced  to  a  minimum. 

It  consists  of  two  parallel,  hardwood  bars  united  with  folding  cross-bars 
of  steel  or  wrought  iron.  Care  should  be  taken,  however,  to  secure  a 
strong  construction  at  the  joints,  as  otherwise  the  brace,  under  a  heavy 
weight,  may  be  bent  at  this  point.  The  side-bars  are  usually  of  straight 
grain  ash,  7  feet,  6  inches  long,  \y2  inches  wide  and  i^  inches* thick.  The 
canvas  should  be  12  ounce  duck,  6  feet  2  inches  in  length,  by  2  feet  2 


TRANSPORTATION  OF  THE  SICK  AND  WOUNDED. 


913 


inches  in  width.  The  legs  or  supports  are  stirrup-shaped,  usually  of  malle- 
able iron,  and  of  such  height  that  they  will  raise  the  under  surface  of  the 
bars  4  inches  above  level  ground.  Each  should  be  supplied  with  a  litter- 


United  States  Array  Stretcher,  Pattern  1895. 


Showing  the  Cross  Bars  and  Method  of  Folding. 


Figure  -.2219.     Showing  Stretcher  Folded  for  Transportation. 

sling  adjustable  to  carriers  of  various  heights.  Two  leather  straps  should 
be  attached  to  the  under  surface  of  one  of  the  side  bars  that  the  whole  may 
be  closely  folded  and  firmly  held. 

Wheel  Litters. 

Wheel  litters,  constructed  especially  for  military  use,  would  seem  almost 
a  necessity.  It  is  well  known  that  a  single  man  can  transport  a  patient  for 
long  distances  by  means  of  a  wheeled  vehicle.  Just  as  the  jinrikisha  of  Japan 
has  superseded  the  old  cago  or  litter  as  a  method  of  transporting  passen- 
gers in  Japan,  so  it  has  been  predicted  by  Andrews  that  some  form  of  a 
wheel  litter  would  take  the  place  of  the  stretcher  now  in  common  use  in 
the  armies  of  the  world. 

The  objections  to  the  use  of  wheel  litters  for  military  use  have  been  prin- 
cipally their  want  of  compactness  and  the  rough  nature  of  the  ground  over 
which  they  must  frequently  be  used.  The  first  objection  ought  not  to 
prove  a  serious  one  because  some  form  of  cart  with  light  removable  wheels 
can  be  constructed,  or  a  stretcher  adjusted  to  rest  on  the  handle  bars  and 
seat  of  a  bicycle. 

As  civilization  advances,  the  character  of  battle  grounds  gradually  im- 
proves for  the  better.  Rapid  transportation,  particularly  for  wheeled  vehi- 
cles, is  more  easily  secured ;  cultivation  removes  underbrush ;  fences  are 
either  abandoned  or  are  of  wire  and  easily  cut ;  roads  are  more  common ;  in 
fact,  all  conditions  appear  more  favorable  for  the  use  of  such  appliances 
than  in  former  years.  If  a  suitable  device  be  found,  it  would  either  en- 
able a  hospital  corps  to  accomplish  two  or  three  times  as  much  work  as 
with  the  ordinary  forms  of  stretchers,  or  permit  the  reduction  of  the  force 
fully  one  half. 

Getz'  Bicycle  Litter  practically  consists  of  a  hand  stretcher  that  with 
a  few  adjustments  may  be  attached  to  an  ordinary  bicycle  wheel.  The 
stretcher  frame  is  6  feet  long  and  26  inches  wide,  so  that  it  will  pass 
through  an  ordinary  doorway  or  a  railroad  car  window.  It  is  manufactured 

58 


914 


MILITARY    SURGERY. 


from  bicycle  tubing  and  weighs  about  8  pounds.  It  is  quickly  removed  from 
the  bicycle  and  is  arranged  to  be  carried  over  the  shoulder  of  the  rider 
when  going  to  the  scene  of  accident  or  battle.  The  rider  sits  upon  one  of 
the  cross-arms  or  stretcher  supports  while  the  second  or  front  stretcher 
support  is  employed  as  a  handle-bar.  On  dismounting,  the  stretcher  may 
be  quickly  secured  to  the  cross-arms  and  with  the  aid  of  one  assistant,  the 

I 


Figure  3220.    Getz's  Bicycle  Litter. 

patient  may  be  easily  placed  on  the  stretcher  and  the  latter  attached  to  the 
bicycle.  In  loading,  the  patient  may  be  rolled  upon  his  side,  the  stretcher 
frame,  while  attached  to  the  bicycle,  placed  lengthwise  against  his  back  and 
legs,  when  the  patient  and  stretcher  frame  together  may  be  easily  lifted 
into  an  upright  position.  As  the  attendants  are  relieved  of  the  weight  of  the 
injured  person,  a  long  distance,  even  over  rough  ground,  may  be  covered 
in  a  short  time,  without  fatiguing  patient  or  attendants. 

Ambulances. 

It  is  doubtful  whether  any  improvement  over  the  United  States  army 
pattern  can  be  secured.  Many  changes  and  modifications  have  been  made, 
but  the  regular  form  still  seems  to  meet  every  indication  and  fill  ever}'  re- 
quirement. As  this  pattern  is  familiar  to  all  those  interested  in  such 
equipment,  a  detailed  description  will  be  omitted. 


Figure  2221.    United  States  Army  Ambulance. 


The  United  States  Army  Ambulance,  as  pictured  in  figure  2221,  is  of 
the  regular  pattern  proscribed  for  Government  use.  It  is  of  heavy  con- 
struction and  is  fitted  to  accommodate  six  patients,  besides  being  provided 
with  a  water  tank  9  by  16  inches.  Its  sides  are  each  composed  of  three 
white  duck  curtains  which  may  be  rolled  up,  as  shown  in  the  illustration. 


CHAPTER  XXXVI. 


FRACTURES. 

The  mechanical  treatment  of  fractures  necessitates  the  use  of  bandages, 
splints,  appliances  for  the  adjustment  and  removal  of  plaster  of  paris  or 
similar  bandages,  extension  apparatus  and  such  surgical  instruments  as 
may  be  required  for  wiring  or  otherwise  treating  ununited  fractures.  The 
large  majority  of  the  appliances  generally  employed  may  be  improvised  by 
any  mechanical  surgeon,  and  while  it  is  a  convenience  if  one  is  supplied 
with  a  fair  assortment  of  the  apparatus  in  common  use,  the  successful 
treatment  of  a  fracture  depends  more  on  the  knowledge  and  skill  of  the 
surgeon  than  on  the  means  employed  to  secure  perfect  adjustment.  A 
good  surgeon  with  a  saw,  jack-knife,  some  strips  of  cotton  cloth  and  elastic 
material  for  padding,  may  accomplish  far  more  perfect  results  than  a  poor 
or  careless  surgeon,  even  if  equipped  with  all  the  appliances  enumerated 
in  this  chapter.  While  this  applies  to  the  treatment  of  all  forms,  it  may  be 
applied  with  greater  force  to  simple  fractures. 

As  the  surgeon,  when  suddenly  called,  can  not  know  the  character  of 
the  injury  he  is  to  treat,  he  should  be  provided  with  at  least  a  limited  as- 
sortment of  surgical  necessities  such  as  might  be  employed  in  the  treat- 
ment of  a  compound  comminuted  fracture  or  an  amputation.  McDonald 
advises  that  the  surgeon  provide  himself  with  an  emergency  satchel 
equipped  for  the  treatment  of  fractures,  in  which  he  should  keep  at  least 
the  following: 

Needles. 

Absorbent  Cotton. 

Prepared  Catgut. 

Roller  Bandages. 

Antiseptic  Tablets. 

2  Bistouries. 

lodoform  and  Sublimate  Gauze. 

6  Hemostatic  Forceps. 

Male  Catheter. 

Scissors. 

Chloroform. 

Hypodermic  Syringe. 

Solution  of  Cocaine,  4  per  cent. 

Esmarch's  Syringe. 

Razor 

Collodion. 

Plaster  of  Paris  Bandages. 

Hand  Brush. 

To  this  we  would  suggest  the  addition  of  a  heavy  knife  with  saw  blade 
as  portrayed  in  figure  2210,  a  roll  of  adhesive  plaster  and  a  rubber  bandage. 

915 


910  FRACTURES. 

BANDAGES. 

These,  with  the  exception  of  the  triangular  bandage,  having  been  fully 
described  in  a  previous  chapter,  require  no  further  description. 

Triangular  Bandages,  as  illustrated  by  figure  799,  are  made  by  cutting 
a  square  of  cloth  diagonally  from  corner  to  corner  forming  two  right-angled 
triangles  of  equal  size  and  shape.  They  are  particularly  adapted  for  mili- 
tary, police  and  other  emergency  use. 


SPLINTS. 

These  consist  of  strips,  bands  or  appliances  of  special  shape,  composed  of 
wood,  metal,  plastic  material,  or  other  substance  used  to  immobilize  or 
support  a  joint,  bone  or  part,  when  from  injury,  disease  or  operation,  its 
functions  are  partially  or  wholly  impaired.  They  may  be  classified  as 
movable  and  immovable  splints,  the  latter  often  called  hardened  bandages. 

Movable  Splints. 

These  comprise  those  forms  that  are  applied  or  held  in  place  by  band- 
ages, straps  or  such  other  devices  as  will  admit  of  the  removal  and  re- 
application  of  the  splint  when  desired.  The  materials  in  use  for  general 
purposes  are :  wood,  wire  gauze,  poroplastic  felt,  hatters'  felt,  gutta- 
percha,  leather,  binders'  board,  plaster  of  paris,  and  metal. 

Splints  for  special  fractures,  as  'suggested  by  different  authors,  are  of 
various  substances  according  to  the  requirements  of  the  work.  These  will 
be  described  after  first  presenting  forms  of  material  that  may  be  employed 
for  general  use. 

"Wood  Splints. 

Wood,  in  some  one  of  its  various  forms,  is  more  generally  employed 
than  any  other  material  in  the  construction  of  splints.  With  a  piece  of 
pine  or  bass-wood  board,  %  to  yb  of  an  inch  in  thickness,  and  a  good 
pocket  knife,  there  are  few  splints  required  that  can  not  be  improvised  by 
any  surgeon  of  average  mechanical  ability.  It  is,  however,  of  advantage 
to  the  surgeon  and  usually  more  satisfactory  to  the  patient,  to  employ  a 
specially  manufactured  splint  or  appliance,  even  though  no  better  results 
may  attend  its  use. 

Manufactured  wood  splints  for  general  use  can  be  procured  in  a  multi- 
tude of  forms. 


Figure  2223.    Set  of  Coaptation  Splints.  .  Figure  2224.    Gooche's  Wood  Splinting. 

Coaptation  Splints,  as  usually  found  in  the  market  and  as  shown  by  fig- 
ure 2223,  consist  of  thin,  light  wooden  strips  one  side  of  which  is  covered 


SPLINTS. 


917 


with  muslin  firmly  secured  by  glue  or  other  adherent  substance.  Creases 
or  incisions  penetrating  partly  through  the  wood  are  placed  about  one  inch 
apart  and  extend  the  full  length  of  the  splint.  This  enables  the  operator 
to  roll  the  material,  thus  adapting  it  closely  to  a  limb  of  any  size.  Those 
manufactured  from  bass-wood  or  other  light  wood  may  usually  be  procured 
in  sets  of  five  pieces,  3  inches  in  width,  and  varying  in  length  from  6^  to 
10  inches. 

Gooche's  Wood  Splinting,  as  illustrated  in  figure  2224,  consists  of  nar- 
row strips  of  wood  fastened  together  with  cloth.  As  the  cloth  is  on  one 
side  only,  the  surgeon  may  roll  it  evenly  and  compactly.  When  cut  into 
splints,  as  it  may  be  with  a  heavy  knife  or  saw,  it  can  be  rolled  around  the 
limb,  thus  affording  a  close  fit  and  good  support.  Its  usual  width  is  about 
1 8  inches. 


Figure  2225.     Yucca  Splint  Material. 

Yucca  Splints,  as  sketched  in  figure  2225,  are  manufactured  from  a  spe- 
cies of  yucca  indigenous  to  Southern  California.  The  wood  is  extremely 
porous  and  pliable,  yet  possesses  sufficient  strength  for  splinting  purposes. 
It  may  be  purchased  in  sheets  from  y2  to  ye  of  an  inch  in  thickness,  in 
which  form  it  may  be  cut  with  scissors  or  a  pocket  knife,  particularly  if 
moistened.  While  its  fibers  present  considerable  firmness  longitudinally, 
the  material  can  be  rolled  laterally  so  that  a  flat  piece  of  it  may  be  closely 
curved  to  fit  the  contour  of  the  smallest  limb.  As  it  contains  no  foreign 
substance  employed  to  strengthen  or  bind  its  fibers  together,  it  is  compara- 
tively aseptic.  When  moistened,  it  may  be  accurately  molded  to  fit  irregu- 
lar surfaces.  Being  light  and  porous,  it  forms  a  comfortable  dressing  or 
support  and  possesses  a  further  advantage  in  that  it  offers  no  resistance  to 
the  X-ray. 

"Wire  Gauze. 

This  substance  possesses  many  advantages  as  a  material  from  which  to 
construct  splints.  As  it  possesses  great  flexibility,  it  can  easily  be  molded 
into  almost  any  form.  Being  firm,  yet  light,  its  weight  is  not  objection- 
able to  the  patient ;  as  it  has  a  porous  structure,  it  admits  of  the  free  pass- 
age of  air  or  the  application  of  fluid  medicaments ;  as  it  is  composed  of 
non-absorbable  material,  it  is  or  may  be  rendered  aseptic ;  and  as  it  is  man- 
ufactured on  a  large  scale  for  mechanical  purposes,  it  can  be  purchased  at 
a  low  price. 

A  special  roll  6  inches  wide  and  i  yard  long,  such  as  is  used  in  the  Uni- 
ted States  army  and  shown  by  figure  2211,  is  a  convenient  form. 

The  Shears  for  Cutting  Wire  Gauze,  shown  by  figure  2227,  do  not  differ 
from  those  used  in  tin  shops  excepting  that  they  are  of  a  lighter  pattern. 


918 


FRACTURES. 


The  surgeon  who  is  supplied  with  a  quantity  of  wire  gauze  and  a  pair  of 
strong  shears,  may  quickly  prepare  a  suitable  splint  for  almost  and 
fracture. 


Figure  2226.     Wire  Gauze  for 
Splints. 


Figure  2227.    Shears  for  Cutting  Wire  Gauze. 
Poroplastic  Felt. 


This  substance,  usually  composed  of  wool  and  cotton,  is  matted  to- 
gether without  weaving-,  its  cementing  substance  being  a  preparation  of 
shellac  or  other  resinous  drug.  This  forms  a  material  not  softened  by 
moisture  or  wetting,  though  readily  affected  by  heat.  It  is  light  and  free 
from  offensive  odor.  It  can  be  purchased  in  sheets,  usually  about  a  yard 
in  width,  from  which  splints  of  any  size  and  form  may  be  cut  with  a  sharp 
knife.  It  may  be  softened  by  immersion  in  hot  water,  placing  it  in  a  hot 
oven,  or  suspending  it  by  a  string  and  rotating  it  over  a  stove,  hot  register, 
or  before  a  fire.  When  soft,  it  may  usually  be  stretched  sufficiently  to  fit 
over  a  protuberance  or  to  fill  in  a  depression.  The  cutting  of  notches  to 
secure  a  good  fit  should  be  avoided,  but  if  made,  they  should  be  covered 
by  stitching  a  piece  over  them,  using  strong  twine  for  sewing.  If  it  has 
to  be  worn  for  some  time,  the  edges  may  be  pared  thin  to  avoid  linear  cor\- 
striction  and  where  desirable,  perforations  may  be  made  to  give  free  access 
to  the  air,  in  addition  to  which,  it  may  be  lined  with  soft  material.  Usually 
they  should  be  applied  over  some  elastic  substance,  as,  for  instance,  a  flan- 
nel bandage.  The  retaining  bandage  should  be  evenly,  uniformly  and 
firmly  applied  before  the  splint  becomes  fixed. 

Hatters'  Felt. 

This  differs  from  poroplastic  felt  in  being  non-porous  and  composed  of 
separate  layers  of  ordinary  muslin,  the  whole  mass  being  saturated  with  a 
shellac  compound.  It  is  a  firm,  hard  material,  thinner  and  yet  stronger 
than  the  poroplastic  variety.  It  is  applied  in  the  same  manner. 

G-utta-Percha. 

This  material  differs  but  little  from  crude  rubber,  excepting  that  it  is 
manufactured  into  sheets  of  from  %  to  %  of  an  inch  in  thickness.  It 
should  not  be  confounded  with  hard  or  vulcanized  rubber  from  which  it 
differs  in  being  more  plastic.  It  is  easily  softened  in  hot  water,  but  if  sub- 
jected to  this  heat  for  too  long  a  time,  it  becomes  soft,  sticky  and  difficult  to 
handle.  As  it  does  not  cool  readily,  the  surgeon  need  not  exercise  undue 
haste  in  forming  a  splint  from  it. 

Before  application,  the  limb  should  be  thoroughly  oiled  to  prevent  the 
gutta-percha  from  adhering  to  the  skin.  After  being  thoroughly  softened, 
a  piece  of  the  proper  size  may  be  placed  upon  the  limb  and  shaped  to  con- 
form to  any  inequalities  of  the  parts.  It  may  be  stretched  to  pass  over 
protuberances,  and  folded  over  or  cut  where  hollows  or  angles  are  encoun- 


SPLINTS.  919 

tered.  When  necessary,  a  portion  of  the  splint  may  be  cut  away,  the 
space  being  filled  by  a  small  patch  of  the  same  material  pressed  into  posi- 
tion while  quite  hot.  After  being-  formed,  the  splint  should  be  bandaged 
in  place  until  it  has  acquired  some  degree  of  firmness,  when  the  bandages 
may  be  severed  and  the  splint  removed  and  placed  in  cold  water  to  hasten  the 
hardening  process.  A  much  better  fit  may  be  produced  by  softening  the 
splint  where  required  by  means  of  a  hot  iron  applied  to  its  outer  surface. 
It  may  be  strengthened  by  additional  patches  of  the  same  material 
wherever  necessary,  perforated  with  holes  of  any  desired  size  and  lined 
with  chamois  leather. 

Leather. 

Splints  from  this  material  may  be  shaped  in  the  same  manner  as  the  poro- 
plastic  substance  previously  described.  The  material  for  a  given  splint 
should  be  cut  to  the  desired  size  and  soaked  for  24  hours  in  cold  water. 
In  cases  where  an  immediate  application  is  necessary,  the  softening  process 
may  be  hastened  by  the  addition  of  vinegar,  diluted  with  water,  one  to 
four.  This  procedure  should,  however,  be  avoided  as  it  tends  to  toughen 
or  harden  the  material. 

After  pressing  out  all  superfluous  water,  the  leather  may  be  applied 
directly  to  the  part,  where  it  should  be  accurately  fitted.  When  it  is  nec- 
essary to  cut  out  portions  of  the  material,  stitches  of  heavy  thread  should 
be  inserted.  Pads  may  be  placed  in  hollows  and  concavities,  and  over  all  a 
roller  bandage  should  be  carefully  applied.  Rest  and  fixation  of  the  parts 
should  be  secured  until  the  leather  has  hardened  sufficiently  for  removal, 
after  which  it  may  be  cut,  trimmed  and  lined  as  may  be  necessary. 

If  the  surgeon  for  any  reason  does  not  care  to  undertake  the  manufac- 
ture of  a  leather  splint,  he  may  make  a  plaster  of  paris  cast  of  the  part, 
which  he  can  forward  to  his  instrument  maker  with  the  necessary  instruc- 
tions for  the  proper  execution  of  his  order. 

Binders'  Board. 

This  is  much  employed  as  splint  material,  especially  in  fractures  of 
the  arm  and  hand,  and  in  children  generally.  It  is  obtainable  from  instru- 
ment dealers  and  printing  offices.  It  may  be  cut  into  strips  or  pieces  of 
any  desired  shape  and  applied  plain  or  it  may  be  immersed  in  boiling 
water  until  soft  and  then  molded  to  fit  the  limb. 

Plaster  of  Paris  Splints. 

The  regular  "immovable"  plaster  of  paris  splint  can  be  transformed 
into  a  "movable"  one  by  removing  it  in  the  usual  manner,  after  which  it 
may  be  lined  with  cloth  or  leather,  and  the  edges  bound  with  the  same  ma- 
terial. Eyelets  or  lacing  hooks  may  be  attached  to  the  edges  by  which  the 
splint  can  be  replaced  and  laced  up  like  a  shoe  or  corset.  These  changes 
can  be  made  by  a  shoemaker  or  the  splint  may  be  sent  to  an  instrument 
house. 

Metal  Splints. 

These  are  constructed  from  such  a  variety  of  materials  that  a  full  de- 
scription of  each  seems  impracticable.  Tin,  zinc,  or  galvanized  iron  may 
be  employed,  the  services  of  a  neighboring  tinner  being  called  into  use  if 
necessary.  Brass,  aluminum,  iron  wire,  and  various  other  substances  can 
be  utilized  to  a  greater  or  lesser  extent,  depending  entirely  upon  the 
mechanical  resources  of  the  surgeon. 


920  FRACTURES. 

Immovable  Splints. 

Hardened  bandages  are  manufactured  from  some  loosely-woven  fabric, 
the  meshes  of  which  are  filled  with  a  plastic  chemical  mass  that  hardens  or 
solidifies  upon  exposure  to  air.  Such  splint  material  is  applied  while 
in  a  plastic  state,  immobility  of  the  parts  being  secured  until  the  hardening 
process  is  complete.  They  are  employed  to  secure  fixation  when  by  reason 
of  fracture,  disease  or  other  cause,  immobility,  support  or  rest  is  desired. 
They  are  not  only  used  on  the  extremities  but  on  the  trunk,  pelvis,  etc. 
Various  materials  are  employed  for  this  purpose,  among  the  more  impor- 
tant of  which  are  plaster  of  paris,  silicate  of  soda,  and  starch. 

Two  methods  are  in  use  for  incorporating  the  chemicals  with  the  cloth. 
One  consists  in  covering  the  part  to  be  enclosed  by  the  splint  with  the 
bandage  or  other  splint  fabric,  and  smearing  over  and  rubbing  into  it  the 
solidifying  compound  which  should  be  of  a  semi-fluid  consistency.  Ad- 
ditional layers  of  cloth  and  the  splint  material  are  alternated  until  the 
desired  thickness  is  obtained. 

The  second  method,  devised  by  Sayre,  and  the  one  more  commonly  em- 
ployed, consists  in  forming  the  splint  of  loosely  woven  bandages,  the 
meshes  of  which  have  been  previously  filled  with  solidifying  substance. 
Many  surgeons  combine  these  methods  by  smearing  over  and  rubbing  into 
each  succeeding  layer  of  prepared  bandages,  a  quantity  of  the  hardening 
compound,  thus  insuring  complete  impregnation  of  the  bandage  meshes, 
and  layer  spaces  with  the  agent. 


Plaster  of  Paris  Bandages  each  in  a  Metal  Box. 


Plaster  of  Paris  Splints. 

Plaster  of  Paris  Bandages  may  be  prepared  by  the  surgeon  or  purchased 
ready  for  use.  Surgeons,  however,  should  avoid  purchasing  plaster  of  paris 
bandages  from  dealers  who  keep  them  on  hand,  for  once  manufactured  and 
placed  in  stock,  he  usually  has  no  guarantee  as  to  their  age  or  freshness. 
Physicians'  supply  houses  should  provide  themselves  with  the  necessary 
appliances  for  the  proper  preparation  of  plaster  of  paris  bandages,  and  like 
prescriptions,  fill  them  after  the  order  is  received.  Unless  the  surgeon 
finds  that  he  can  procure  from  the  dealer  bandages  in  which  the  plaster  is 
still  active,  he  will  obtain  better  results  by  preparing  them  himself,  which 
he  can  do  by  the  following  method: 

The  cloth  selected  should  be  one  capable  of  absorbing  the  largest  possi 
ble  quantity  of  the  plaster  of  paris,  and  at  the  same  time  present  the  small 
est  quantity  of  fiber  at  the  surface.     Crinoline  muslin  is  generally  pre- 
ferred, although  an  open-mesh  variety  of  cheese-cloth  is  used  by  many  sur- 
geons.    A  cloth  with  a  fine  or  closely-woven  mesh  will  not  hold  or  carry 
enough  plaster  to  form  a  stiff  bandage,  and  it  will  hold  too  much  moisture 


SPLINTS. 


921 


and  for  too  long  a  time  to  admit  of  rapid  hardening ;  while  a  cloth  with  too 
coarse  a  mesh,  like  mosquito  netting,  will  result  in  a  jacket  that  will  lack 
elasticity,  and  will  chip  or  break  easily.  The  material  selected  should  be 
torn  into  strips  from  two  to  three  inches  in  width  and  cut  into  the  lengths  de- 
sired, usually  from  three  to  six  yards.  As  the  degree  of  success  attained 
will  depend  much  on  the  character  of  the  plaster  employed,  care  must  be 
exercised  in  its  selection.  The  quality  should  be  that  known  as  the  extra 
calcined  or  dental  plaster,  such  as  is  used  by  dentists,  and  must  be  perfectly 
dry  and  free  from  lumps  or  hard  masses.  The  presence  of  the  latter 
would  indicate  that,  while  the  plaster  may  be  dry  at  the  time  of  examination, 
it  has  at  some  period  in  the  past  absorbed  moisture,  and  as  a  consequence 
much  of  its  activity  has  been  destroyed.  Inert  plaster  not  only  hardens 
slowly,  but  its  use  will  result  in  a  splint  deficient  in  strength  and  power  of 
fixation. 

The  plaster  may  be  incorporated  with  the  cloth  strips  by  laying  the  lat- 
ter on  a  board  or  table  and  dusting  the  plaster  over  them,  rubbing  the 
latter  into  the  meshes  of  the  cloth  until  it  is  thoroughly  impregnated  with 
the  powder,  after  which  the  bandage  should  be  carefully  rolled  into  a  cylin- 
der and  stored  in  air-tight  cans,  as  shown  in  figure  2228,  until  wanted  for 
use.  Care  must  be  exercised  to  see  that  the  bandages  are  free  from  lumps, 
uneven  surfaces,  etc.  Machine-spread  plaster  bandages  are  more  even 
than  those  prepared  by  hand,  and  to  those  who  make  use  of  plaster  of  paris 
bandages  in  large  quantities,  we  recommend  the  following  apparatus: 

The  Bellevue  Plaster  Bandage  Roller,  as  originally  designed,  was  faulty 
in  construction  because  the  powder  was  at  all  times  inclined  to  mass  in  the 
throat  of  the  hopper,  thus  furnishing;  an  uneven  spread.  At  the  suggestion 


Figure  2229.     Improved  Bellevue  Plaster  Bandage  Roller. 

of  McMorris,  the  author  instituted  a  series  of  experiments  resulting  in  the 
improved  device  illustrated  by  figure  2229.  With  it  the  surgeon  or  his  as- 
sistant can  prepare  his  bandage  "fresh"  for  each  case,  and  this,  too,  with- 
out soiling  his  clothes.  The  bandages  can  also  be  rolled  evenly  with  the 
proper  degree  of  tension  and  the  meshes  completely  filled  with  the  pow- 
dered plaster. 

It  is  customary  to  apply  a  plaster  of  paris  bandage  over  a  first  covering 


922  FRACTURES. 

or  bandage  that  is  soft,  flexible  and  elastic,  care  being-  taken  to  utilize  such 
material  as  has  been  thoroughly  shrunken,  because  if  contraction  of  the 
primary  bandage  takes  place  after  the  application  of  the  splint,  the  pain 
caused  to  the  patient  might  necessitate  the  removal  of  both  the  first  dress- 
ing and  the  splint. 

"  In  preparing  a  limb  for  such  a  splint,  care  should  be  taken  to  fill  it  out 
evenly  and  smoothly,  using  as  a  padding  plain  cotton,  jute,  oakum,  etc.  It 
may  be  useful  to  know  that  plaster  of  paris  may  be  removed  from  the 
hands  by  washing  them  in  a  solution  of  carbonate  of  soda,  about  one  table- 
spoonful  to  the  pint  of  water. 

Silicate  of  Soda  Splints. 

Liquid  glass  or  silicate  of  soda  is  occasionally  employed  in  the  construc- 
tion of  immovable  splints.  It  possesses  the  advantage  of  being  lighter 
than  plaster  of  paris,  while  its  use  is  accompanied  with  the  disadvantage 
of  requiring  a  longer  time  to  harden.  It  is  applied  in  a  manner  similar  to 
plaster  of  paris  excepting  that  the  bandages  are  either  immersed  until 
the  meshes  are  filled  with  the  soda  solution,  or  the  plain  bandages  applied 
as  for  a  starch  bandage,  and  the  soda  rubbed  in  with  a  brush,  the  limb 
having  been  previously  prepared  in  the  manner  just  described.  They  re- 
quire six  hours  to  harden.  They  may  be  softened  with  warm  water  along 
the  proposed  line  of  incision,  after  which  they  may  be  cut  with  heavy 
shears  or  scissors. 

Starch  Splints. 

These  are  applied  by  mixing  starch  with  warm  water  until  a  thick  pasty 
mass  results.  This  is  then  diluted  with  boiling  water  until  a  clear  mucil- 
aginous liquid  remains.  It  should  be  of  about  the  same  consistence  as 
that  employed  in  a  laundry.  The  part  to  be  enclosed  by  the  splint  should 
be  first  covered  with  a  flannel  bandage,  after  which  the  gauze,  crinoline  or 
other  bandage  cloth  should  be  applied,  two  to  four  layers  thick.  Over  this 
the  starch  should  be  smeared,  care  being  taken  to  rub  it  in  until  the  meshes 
of  the  cloth  are  closely  filled  with  the  mass.  This  will  constitute  one 
layer.  These  layers  outside  of  the  flannel  bandage  should  be  applied  one 
over  the  other  until  the  desired  thickness  is  obtained.  The  principal  objec- 
tions to  this  splint  material  are  that  they  require  24  to  36  hours  to  thor- 
oughly harden  and  that  they  are  quickly  softened  by  water. 

Removal  of  Hardened  Bandages. 

Various  instruments  have  been  devised  to  assist  in  the  removal  of  plas- 
ter of  paris  and  similar  bandages,  among  the  more  useful  of  which  are 
knives,  saws,  and  shears. 

Plaster  Bandage  Knives. 

These  are  constructed  with  short,  stout  blades,  for  only  with  a  knife 
especially  designed  for  this  purpose  can  a  surgeon  hope  to  successfully 
remove  bandages  of  this  kind. 

In  this  connection  it  is  perhaps  well  to  remember  that  strong  vinegar 
produces  a  softening  or  decomposing  effect  on  plaster  of  paris  bandages. 
Unlike  muriatic  and  other  strong  mineral  acids  there  is  no  danger  attend- 
ing its  use,  for  it  will  not  harm  the  skin  if  brought  in  contact  with  it. 

Ridlon's  Plaster  Knife,  as  set  forth  in  figure  2230,  contains  a  short 
pruning  blade  of  extra  thickness  in  the  shank  and  thin  at  the  point  for  use 


PLASTER    BANDAGE    KNIVES    AND    SAWS. 


923 


in  cutting  down  plaster  corsets  and  such  splints  as  the  surgeon  may  desire 
to  preserve  in  perfect  shape.  The  pen-blade  is  used  when  it  is  not  desired 
to  preserve  the  jacket  or  splint.  Being  entered  obliquely,  layer  by  layer 


Figure  2230.    Ridlon's  Plaster  Knife. 


of  the  plaster  bandage  rises  as  it  is  cut  through,  all  troublesome  wedging 
of  the  knife  is  avoided,  and  the  chances  of  wounding  the  patient  are  less- 
ened. The  third  blade  is  a  nail  file  with  Curley's  patent  burnisher. 

Esmarch's  Knife  and  Wedge,  as  illustrated  in  figure  2231,  consists  of  a 
short  blade  of  unusual  thickness,  terminating  in  a  heavy  shank,  mounted  in 
a  handle  of  sufficient  diameter  to  afford  a  firm,  full-handed  grasp.  The 


Figure  2231.    Esmarch's  Knife  and  Wedge. 

end  of  this  handle  opposite  the  blade  is  a  sharp,  conical  point,  that  can  be 
used  for  puncturing  a  plaster  jacket,  or  for  tearing  away  shreds  of  cloth  or 
masses  of  plaster  not  easily  cut  with  the  knife.  The  cutting  edge  of  the 
knife  blade  is  il/2  inches  long,  while  the  entire  length  of  the  instru- 
ment is  7  inches. 


Figure  2232.    Steele's  Skin  Protector,  for  Use  in  Removing  Plaster  of  Paris  Bandages. 

Steele's  Skin  Protector,  shown  by  figure  2232,  consists  of  a  small  steel 
plate  about  i  */2  by  2  inches,  attached  by  its  upper  flat  surface  to  a  fixed 
handle  or  shank,  the  latter  joined  at  an  oblique  angle  with  the  plate. 

It  is  employed  to  prevent  injury  to  the  skin  during  the  removal  of  plaster 
of  paris  bandages  by  knives,  saws,  or  similar  instruments.  When  in  use,  it 
is  passed  underneath  the  bandage  along  the  line  of  incision,  and  for  this  pur- 
pose is  provided  with  an  upper  face  of  zinc  or  other  soft  material  to  pre- 
vent injury  to  the  edge  of  the  knife  or  other  instrument  employed. 

Plaster  Bandage  Saws. 

Saws  may  be  utilized  in  the  removal  of  plaster  of  paris  bandages,  be- 
cause the  fibers  of  the  cloth  layers  are  so  firmly  embedded  in  and  cemented 
together  by  the  plaster  mass,  that  they  may  be  sawed  across  in  the  same 
manner  as  a  board. 


924 


FRACTURES. 


Von  Bergmann's  Plaster  of  Paris  Bandage  Saw,  depicted  in  figure  2233,  con- 
sists of  a  short,  stout  saw  blade,  formed  with  an  oval  cutting  surface,  and 
provided  with  a  metallic  handle  shaped  to  afford  a  firm  grasp.  This  in- 


Figure  2833.    Von  Bergmann's  Plaster  of  Paris  Bandage  Saw. 

strument  is  probably  the  best  of  its  class,  as  from  its  peculiar  shape  it  is 
not  liable  to  catch  in  the  meshes  of  the  cloth,  but  on  the  contrary,  with  the 
exercise  of  a  reasonable  amount  of  force,  it  makes  a  clean  incision. 


Steele's  Bandage  Saw. 


Steele's  Bandage  Saw,  as  shown  in  figure  2234,  consists  of  two  parallel, 


equal-sized  blades  separated  from  each  other  about  ^  an  inch.  The  blades 
are  nearly  square  in  general  form,  one  side  presenting  a  slight  convex 
margin.  With  this  instrument,  a  strip  of  the  bandage  y2  an  inch  in  width 
may  be  removed.  This  will  be  found  advantageous,  particularly  in  cases 
where  a  jacket  is  to  be  reapplied.  This  not  only  furnishes  space  for  the 
cloth  or  leather  necessary  to  protect  the  edge,  but  makes  partial  recom- 
pense for  the  loosening  of  the  bandage  often  caused  by  atrophy  of  the  soft 
tissues.  If  preferred,  one  blade  may  be  removed  and  the  other  used 
singly. 


Figure  2235.    Gowan's  Plaster  Bandage  Saw. 


Gowan's  Plaster  Bandage  Saw  is  well  traced  in  figure  2235.  As  this 
instrument  possesses  great  leverage,  with  it  the  operator  may  easily  cut 
through  a  bandage  of  any  length  or  thickness.  As  it  has  a  circular,  saw- 
toothed  edge,  there  is  no  danger  of  its  becoming  entangled  in  the  meshes 
of  the  cloth,  and  from  its  peculiar  shape  it  is  as  well  adapted  for  cutting 
through  solid  masses  of  cloth  as  through  sections  consisting  almost  entirely 
of  plaster.  There  is  no  possibility  of  injuring  the  skin  or  soft  tissues  of  the 


PLASTER    BANDAGE    SHEARS. 


925 


patient,  because  as  shown  in  the  illustration,  a  plow  point  or  guide  is  pro- 
vided that,  when  in  use,  passes  underneath  the  splint  or  between  the  splint 
and  the  cutaneous  surface.  Its  length  is  from  14  to  15  inches. 

Plaster  Bandage  Shears. 

Shears  in  some  form  are  more  generally  employed  to  remove  plaster 
bandages  than  any  other  class  of  instruments.  As  something  more  effi- 
cient than  the  mere  crushing  force  exhibited  in  the  ordinary  shears  is  de- 
manded, inventors  have,  by  various  devices,  sought  to  increase  the  lever- 
age by  compounding  it,  placing  the  pivot  or  fulcrum  so  as  to  impart  a  slid- 
ing motion  to  the  edge,  or  to  make  the  latter  circular,  so  that  only  a 
limited  extent  of  the  surface  to  be  incised  is  within  the  bite  of  the  shears 
at  any  one  time. 


Fi 


Lister's  Bandage  Shears,  as  illustrated  in  figure  2236,  consist  of  a 
strongly-built  pattern,  the  under  blade  of  which  is  provided  with  a  circular 
probe-shaped  point,  the  upper  face  of  which  is  beveled  that  it  may  more 
easily  be  forced  underneath  the  bandage  to  be  cut.  As  it  has  scissors  han- 
dles, its  force  is  necessarily  limited.  Its  chief  advantage  is  the  low  price 
at  which  it  can  be  purchased.  The  usual  length  is  8  inches. 


Figure  2237.     German  Plaster  Bandage  Shears. 

The  German  Plaster  Bandage  Shears,  shown  in  figure  2237,  differ  from 
the  Lister,  last  described,  only  in  the  construction  of  their  joint  and  in  being 
heavier.  The  pivot  which  forms  the  lock  in  this  pattern  is  placed  in  a  pro- 
jection on  the  upper  sides  of  the  blades  and  is  so  adjusted  that  it  imparts 
to  the  upper  or  moving  blade  an  eccentric  combined  sliding  and  cutting 
motion  that  is  more  effectual  than  the  simple  crushing  force  of  the  ordinary 
shears.  The  instrument  is  strongly  built,  and  is  usually  about  9  inches  in 
length. 

Wight's  Bandage  Shears,  as  portrayed  in  figure  2238,  are  the  heaviest 
pattern  in  this  class  of  instruments.  The  under  or  fixed  blade  is  provided 
with  a  concave  upper  surface,  while  the  upper  or  moving  blade  consists  of 
a  convex  surface,  the  two  so  adjusted  as  to  furnish  a  cutting  power  of  un- 


926 


FRACTURES. 


usual  force.  The  handles  are  large  and  heavy,  affording  the  operator  the 
best  possible  grasp  that  can  be  scoured  with  a  shear-handled  instrument. 
Their  length  is  10^4  inches. 


Figure  2238.    Wight's  Bandage  Shears. 

Von  Brim's  Bandage  Shears,  depicted  in  figure  2239,  furnish  an  example  of 
a  compound  lever  applied  to  a  short,  stout  cutting  blade,  with  a  slight  cir- 


Figure  2239.    Von  Brun's  Plaster  Shears. 

cular  or  convex  surface.  The  instrument  is  possessed  of  sufficient  power 
to  enable  the  surgeon  to  cut  through  a  bandage  with  slight  difficulty.  Its 
length  is  13  inches. 

General  Splints. 

Parkhill's  Clamps  for  Bone  Approximation,  as  shown  in  figure  2240, 
comprise  a  set  of  four  screw  shafts,  to  each  of  which  an  L-shaped  wing- 
plate  is  attached  at  a  right  angle.  When  inserted  in  the  ends  of  the  bones 
to  be  united,  the  four  shafts  should  be  in  line,  two  upon  either  side  of  the 


Figure  2240.    Parkhill's  Clamp  to  Secure  Approximation  Following  Fractures  and  Resections. 

crevice.  The  wing-plates  attached  to  the  two  inner  shafts  are  each  about 
y2  an  inch  shorter  than  the  outer  ones,  this  distance  usually  representing 
the  amount  of  space  between  the  two  outer  posts.  The  lower  end  of  each 
shaft  is  supplied  with  a  thread  that  it  may  be  screwed  into  a  drill  hole  pre- 


SPLINTS. 


927 


viously  prepared  in  the  bone.  The  upper  end  is  also  threaded,  enough  of 
the  top  of  the  shaft  being  squared  to  permit  the  application  of  a  clock  key 
by  which  it  is  screwed  into  place.  The  upper  threaded  portion  is  supplied 
with  two  nuts,  one  above  and  the  other  below  the  wing- plate,  by 
which  the  latter  may  be  secured  in  any  desired  position.  Each  shaft 
should  be  long  enough  to  project  through  the  soft  tissues,  leaving  space 
between  the  wing-plates  and  the  integument  for  the  application  of  the 
clamp.  When  in  position,  one  wing  of  each  bar  overlies  its  mate,  the  two 
longer  and  the  two  shorter  blades  resting  side  by  side,  all  four  being  in 
such  close  approximation  that  they  may  be  firmly  fastened  together  by  the 


Figure  2341.    Showing  Application  of  Parkhill's  Clamps. 

transverse  clamp  and  screws  shown  in  the  illustration.  When  approxima- 
tion is  desired,  two  of  the  shafts  may  be  screwed  into  the  long  axis  of  the 
bone  at  such  points  as  may  be  determined,  by  first  properly  clamping 
the  four  shafts  together  and  marking  on  the  skin  the  points  for  insertion. 
Once  in  place,  immobilization  is  secured  as  long  as  the  clamp  is  permitted 
to  remain.  In  drilling  the  holes  it  is  advisable  to  place  a  steel  pin  in  the 
first  one,  not  only  to  locate  it,  but  to  prevent  its  becoming  filled  while  the 
second  one  is  being  drilled.  To  prevent  oxidation,  the  whole  apparatus 
should  be  silver-plated.  Three  sizes  are  advised,  the  largest  for  operations 
on  the  femur;  the  medium,  for  those  of  the  humerus  and  tibia;  and 
the  smallest  for  the  radius,  fibula  and  clavicle. 


Figure  2242.    Marks'  Modification  of  Parkhill's  Clamps, 

Marks'  Modification  of  Parkhill's  Clamps,  as  exhibited  in  figure  2242, 
according  to  the  statements  of  their  inventor,  are  an  improvement  on  the 
original  pattern.  The  advantages  claimed  are  a  less  number  of  parts,  an 


928 


FRACTURES. 


easier  adjustment,  and  a  tapering  screw,  the  latter  ensuring  immobility 
when  inserted  in  the  drill  hole.  Practically  they  consist  of  four  screw  posts 
that  differ  from  the  pattern  of  Parkhill  only  in  that  the  threaded  por- 
tion is  slightly  conical.  This  latter  feature,  it  is  claimed,  will  prevent  the 
posts  from  self-loosening.  The  four  posts  are  joined  together  by  two'  slot- 
ted clamps  that  overlap  each  other  in  their  centers,  the  iwo  being  attached 
to  the  posts  by  a  series  of  nuts  and  washers,  almost  identical  with  those  used 
by  Parkhill.  By  constructing  the  slots  much  wider  than  the  posts,  any  lat- 
eral deviation  of  the  posts  one  with  the  other  may  be  compensated. 


Splints  for  the  Inferior  Maxillary. 

These  may  be  external  or  inter-dental,  the  latter  being  employed  in 
cases  where  the  teeth  are  all  perfect.  These  consist  of  gutta-percha  molded 
on  the  teeth  after  perfect  coaptation  of  the  fractured  parts. 

Wiring  is  occasionally  employed,  and  often  consists  in  transfixing  one 
section  of  the  fractured  bone  with  a  firm  wire  and  securing  the  ends  around 
one  or  more  teeth.  External  splints  may  consist  of  cloth  or  leather  straps 
and  buckles  or  swaged  metallic  plates  fitting  closely  over  the  integument. 

Hamilton's  Splint  consists  of  a  firm  leather  strap  passing  under  the  chin 
and  buckled  over  the  top  of  the  head.  It  is  held  in  place  by  two  counter- 
straps  of  strong  webbing.  One  of  these  passes  around  the  forehead  and 
base  of  the  skull,  the  second  over  the  top  of  the  head  antero-posteriorly. 
These  are  each  supplied  with  buckles  and  all  are  stitched  together  at 
points  of  crossing. 

The  chin-piece  is  attached  to  the  dependent  portion  of  the  vertical 
strap  in  such  a  manner  as  to  prevent  the  maxillary  strap  from  being  dis- 
placed backward. 


Figure  2243.     Hamilton's  Splint  for  the 
Inferior  Maxillary. 


Figure  2244.    Perforated  Metallic  Splint  for 
the  Inferior  Maxillary. 


The  Perforated  Metallic  Splint  for  fractures  of  the  inferior  maxillary, 
as  represented  in  figure  2244,  is  suitable  only  when  it  properly  fits  the  case 
to  which  it  is  applied.  If  the  surgeon  adopts  a  splint  of  this  character, 


SPLINTS. 


929 


great  care  should  be  exercised  in  its  adjustment  to  see  that  it  is  firmly  pad- 
ded, that  a  close  contact  may  be  secured  along  the  entire  upper  and  lower 
borders  of  the  fractured  part. 

Splints  for  Fracture  of  the  Clavicle. 

Splints  for  fracture  of  the  clavicle  vary  from  a  system  of  plain  band- 
ages to  complicated  designs  in  the  form  of  crutches,  pads,  braces, 
slings,  etc. 


Figure  2345.     Sayre's  Clavicle  Splint. 


Figure  2246.     Levis'  Clavicle  Splint. 


Sayre's  Clavicle  Splint,  as  exhibited  in  figure  2245,  comprises  two  axilla 
and  shoulder  pads  encircling  all  but  the  scapular  side  of  the  shoulder.  Both 
ends  of  each  are  turned  backward  and  attached  to  a  leather  backpiece,  as 
shown  in  the  illustration.  The  leather  is  attached  by  straps  to  a  waist- 
band, by  means  of  which  the  apparatus  is  held  in  proper  position.  That 
portion  of  the  pads  resting  underneath  the  axilla  should  be  of  such  size 
that  it  may  serve  as  a  fulcrum  in  holding  the  shoulder  in  proper  position. 

Levis'  Clavicle  Splint,  as  described  in  figure  2246,  consists  of  a  short, 
firm  axillary  pad,  by  which  the  arm  is  employed  as  a  lever  to  maintain  the 
shoulder  in  proper  position.  To  the  front  and  back  of  the  axillary  pad  are 
fastened  straps  which  pass  directly  upward,  where  they  are  buckled  to  a 
wide  supporting  band  that  passes  across  the  back  and  over  both  shoulders, 
terminating  over  the  chest.  To  this  a  sling  is  suspended,  by  which  the 
arm  is  supported.  A  strap  attached  to  the  elbow  end  of  the  sling,  passing 
obliquely  across  the  back  and  around  the  opposite  side,  is  buckled  to  the 
main  supporting  band.  By  means  of  an  extra  buckle  on  this  band,  the 
apparatus  may  be  reversed  for  the  opposite  shoulder. 

Splints  for  the  Humerus. 

Excepting  when  fractured  close  to  the  head  of  the  bone,  fractures  of 
the  humerus  require  nothing  more  than  the  application  of  a  plain  splint, 
such  as  may  be  supplied  from  the  materials  suggested  earlier  in  this  chap- 
ter. In  cases  involving  a  short  fragment  of  the  upper  end  of  the  bone, 
perfect  coaptation  is  sometimes  secured  only  with  great  difficulty.  In 
extreme  cases,  resort  may  be  had  to  a  special  hook,  similar  in  design  to 
the  last  hooks  employed  by  shoemakers. 

59 


930 


FRACTURES. 


McBurney's  Fracture  Hook,  as  displayed  in  figure  2248,  consists  of  a 
strong  shaft  supplied  with  a  handle  and  terminating  in  a  short,  strong  hook 
bent  at  a  right  angle.  Its  use  requires  an  incision  through  the  soft  parts 


Figure  2348.    McBurney's  Fracture  Hook. 

down  to  the  upper  fragment  of  the  bone.     Into  the  latter  a  hole  should  be 
drilled,  slightly  larger  than  the  diameter  of  the  hook.     A  drill  for  this  pur- 


Figure  2349.    McBurney's  Drill. 

pose  is  shown  by  figure  2249.     By  means  of  the  hook,  direct  traction  may 
be  made  until  coaptation  is  secured. 

Splints  for  the  Elbow. 

Two  varieties  of  splints  may  be  employed  for  fractures  or  resections  in 
or  near  the  elbow  joint.  They  are  known  as  fixed  and  adjustable.  The 
latter  possess  the  advantage  that  a  single  one  may  be  adapted  to  the  require- 
ments of  any  case. 


Figure  2350.    Adjustable  Elbow  Splint. 


Figure  3251.    Fixed  Posterior  Elbow  Splints. 


The  Adjustable  Elbow  Splint,  portrayed  in  figure  2250,  comprises  two 
sections,  one  for  the  arm,  the  other  for  the  forearm,  the  two  being  attached 
by  a  ratchet  joint,  by  which  fixation  at  any  desired  angle  may  be  secured. 
It  may  also  be  applied  anteriorly  or  posteriorly,  or  the  pieces  may  be  sep- 
arated and  used  singly,  thus  giving  to  the  appliance  an  almost  universal 
application. 

The  Fixed  Posterior  Elbow  Splints,  depicted  in  figure  2251,  show  three 
forms  in  which  the  perforated  metal  splints  may  be  purchased.  They  are 
known  to  the  trade  as  acute,  right  and  obtuse  angles,  and  may  be  pur- 
chased in  adults'  and  children's  sizes. 


SPLINTS. 


931 


Splints  for  the  Forearm. 

Splints  for  fractures  and  resections  of  the  forearm  with  fixation  in 
proper  position,  usually  require  that  the  splint  be  extended  to  include  the 
hand. 

The  Forearm  Splint,  sketched  in  figure  2252,  shows  one  of  the  more 
common  forms  of  these  appliances.  The  one  here  exhibited  was  formed 
over  a  cast  taken  from  a  living  subject,  and  is  therefore  accurate  in  shape 


Figure  2252.    Splint  for  the  Ulna  and  Forearm.          Figure  2253.    Levis'  Splint  for  Colics'  Fracture. 

and  contour.     Like  nearly  all  the  perforated  metallic  splints,  it  may  be 
obtained  in  sizes  suitable  for  both  adults  and  children. 

Splints  for  Colles'  Fracture. 

Splints  for  Colics'  fracture  of  the  radius  are  usually  so  formed  as  to 
secure  permanent  fixation  of  the  hand  and  wrist  when  somewhat  flexed. 
They  are  usually  applied  to  the  palmar  side  of  the  arm. 

Levis'  Splint  for  Colics'  Fracture,  as  manifest  in  figure  2253,  consists  of 
a  plate  of  perforated  copper  fitting  closely  to  the  palmar  side  of  the  forearm, 
and  extending  so  as  to  cover  nearly  the  entire  flexed  hand.  The  splint  is 
bent  downward  at  a  point  opposite  the  wrist,  thus  securing  fixation  with 
the  hand  deflected  downward. 


Figure  2254.    Gordon's  Splint  for  Colles'  Fracture. 


Figure  2255.    Carr's  Splint  for  Colles' 
Fracture. 


Gordon's  Splint  for  Colles'  Fracture,  as  exhibited  in  figure  2254,  com- 
prises a  dorsal  and  a  palmar  section,  the  two  united  by  straps  and  bandages. 
The  dorsal  section  is  the  longer,  and  is  bent  downward  to  maintain  the  wrist 
in  a  position  of  semi-flexion.  The  opposite  plate  is  short,  and  carved  or 
padded  to  fit  closely  in  the  interosseous  space  between  the  ulna  and  radius. 
As  generally  found  in  the  market,  they  are  manufactured  from  wood  and 
in  two  sizes. 

Carr's  Splint  for  Colles'  Fracture,  as  sketched  in  figure  2255,  consists  of 
a  plain  wooden  plate,  usually  about  1 1  inches  long  and  2  inches  wide.  The 
outer  end  is  furnished  with  a  round  cross-bar,  obliquely  placed  and  so  formed 
that  when  the  fingers  are  flexed  over  it,  the  hand  is  slightly  adducted. 

Splints  for  the  Metacarpus  and  Phalanges. 

Fractures  of  the  bones  of  the  hand  seldom  require  special  splints  except 
in  cases  where  the  fracture  is  multiple  or  comminuted. 


932 


FRACTURES. 


Wilson's  Metacarpal  Splint,  as  shown  in  figure  2256,  may  be  procured 
for  one,  two  or  more  fingers,  and  for  the  right  or  left  hand. 


Figure  2256.    Wilson's  Metacarpal  Splint. 


Figure  2257.     Phalangeal  Splint. 


The  Phalangeal  Splint,  exhibited  in  figure  2257,  may  be  procured  in 
sets  of  three;  small,  medium,  and  large. 

Splints  for  Fracture  of  the  Patella. 

Owing  to  the  danger  of  displacement  and  the  tendency  to  include  por- 
tions of  the  soft  tissues  between  the  coapting  edges  of  the  fragments,  these 
fractures  require  not  only  immobilization  of  the  knee-joint,  but  means  for 
holding  the  fractured  bones  in  firm  contact  until  union  is  secured.  Many 
methods  are  advised,  varying  from  encircling  the  entire  patella  in  a  loop  of 
wire,  or  the  traction  hooks  of  Malgaigne,  to  a  hardened  bandage  of  plaster 
of  paris. 


Figure  2258.    Malgaigne's  Hooks. 


Figure  2259.     Andrews'  Patella  Hooks  and  Drill. 


Malgaigne's  Hooks,  as  traced  in  figure  2258,  consist  of  two  pairs  of 
semi-circular  hooks,  each  pair  attached  to  a  sliding  plate  in  such  a  manner 
that  the  ends  of  the  hooks  may  be  separated  or  brought  together  by  screw 
power.  When  applied,  the  points  are  passed  through  the  integument  and 
inserted  into  the  upper  and  lower  borders  of  the  fragments.  By  the  use  of 
a  screw  and  wrench,  the  fractured  surfaces  may  be  brought  into  coaptation. 
They  should  be  permitted  to  remain  in  place  until  union  is  obtained.  It  is 
claimed  that  they  are  objectionable  because  the  strain  produced  by  their 
use  causes  pain  and  discomfort. 

Andrews'  Patella  Hooks  and  Drill,  as  shown  by  figure  2259,  consist  of 
two  pairs  of  strong  jaws,  each  terminating  in  short  angular  teeth  and  con- 
trolled by  screw  power.  They  are  applied  by  drilling  small  holes  in  the 
surfaces  of  the  fragments  of  the  patella  in  any  desired  location.  Into  these 
the  points  of  the  clamp  may  be  inserted  and  the  fragments  drawn  firmly 
together  by  the  screws.  The  drill  is  provided  with  a  shoulder  that  prevents 
the  possibility  of  perforating  the  bone  and  opening  the  joint.  By  placing 
these  clamps  one  upon  either  border  of  the  bone,  firm  and  perfect  coapta- 
tion may  be  secured. 

Instead  of  applying  hooks  directly  to  the  fragments  of  the  patella,  Trelat 
advises  that  gutta-percha  plates  be  closely  molded  to  the  limb  above  and 


SPLINTS. 


933 


below  the  patella,  the  two  firmly  bandaged  to  the  limb  and  then  united  by 
hooks,  similar  to  those  of  Malgaigne,  and  coaptation  secured  by  external 
pressure.  This  is  not  generally  considered  an  improvement,  although 
it  is  admitted  that  it  is  more  comfortable  for  the  patient. 

A  fractured  patella  may  be  wired  advantageously  by  employing  a 
curved  needle,  similar  to  those  used  in  operations  on  the  perineum.  This 
needle  may  be  passed  without  ligature  from  below  upward,  around  the 
patella,  threaded  and  withdrawn,  passing  the  wire  in  the  usual  manner. 
The  ends  of  the  wires  are  then  drawn  tightly  together  and  twisted,  the 
skin  being  protected  by  a  firm  plate  that  should  be  a  little  shorter  than  the 
distance  between  the  points  pierced  by  the  needle.  It  is  advised  that  the 
integument,  in  any  of  the  operations  involving  penetration,  be  first  punc- 
tured with  a  knife.  All  the  methods  here  referred  to,  require  the  use  of  a 
back-splint  that  immobilization  may  be  secured. 


Figure  2260.    Agnevv's  Splint  for  Fractures  of  the  Patella. 

Agnew's  Splint  for  Fractures  of  the  Patella,  as  set  forth  in  figure  2260, 
consists  of  a  board  about  30  inches  in  length,  5  inches  in  width  at  one  end 
and  4  at  the  other.  The  upper  surfaces  at  the  ends  are  hollowed  out  to  fit 
the  thigh  and  calf,  the  center  portion  being  straight  to  closely  contact  the 
flattened  surface  underneath  the  knee.  Each  side  is  provided  with  two 
pegs  arranged  for  the  attachment  of  bandages,  which,  by  being  applied 
obliquely,  may  be  employed  to  produce  coapting  pressure,  by  which 
approximation  may  be  secured. 


Figure  2261.     Bacon's  Patella  Support. 


Figure  2262.    Knee  Cap  for  After-Treatment 
of  Fractured  Patella. 


Bacon's  Patella  Support,  as  indicated  in  figure  2261,  is  intended  for  use 
following  partial  recovery  from  a  fracture  of  the  patella,  particularly  with 
aponeurotic  union.  It  consists  of  two  semi-circular  pads  of  firm  material, 
united  at  their  angles  by  a  hinged  joint.  This  is  attached  upon  both  sides 
to  a  hinged  back-bar,  the  terminal  ends  of  which  are  secured  to  the  limb  by 
thigh  and  calf-bands.  Side  straps  attach  the  patella-pad  to  these  bands. 
The  apparatus  is  intended  for  convalescing  patients,  and  is  not  suited  for 
primary  treatment. 

The  Knee  Cap  for  After-Treatment  of  Fractured  Patella,  as  demon- 
strated by  figure  2262,  consists  of  a  cap  made  of  satin- jean,  adjusted  to  the 


934 


FRACTURES. 


knee  by  buckles  or  laces.     It  is  provided  with  a  pair  of  coaptation  pads 
suitable  for  retaining  the  united  fragments  in  place. 

Laces  are  provided,  by  means  of  which  approximation  is  secured.  This 
apparatus  allows  the  patient  to  exercise  the  knee-joint,  thus  guarding 
against  the  tendency  to  ankylosis,  but  at  the  same  time  prevents  any 
undue  strain  on  the  newly-iinited  fragments. 

Splints  for  the  Hip-Joint  and  Upper  Portion  of  the  Femur. 

Fractures  and  resections  of  the  upper  portion  of  the  femur  and  hip-joint 
generally  require  a  fixation  splint.  These  are  usually  applied  in  connec- 
tion with  some  form  of  extension  apparatus. 


Figure  2263.     Long  Extension  Splint. 

The  Long  Extension  Splint,  exhibited  by  figure  2263,  is  usually  from 
4  to  5  inches  in  width,  y2  an  inch  thick,  and  extends  from  the  axilla  to  below 
the  foot.  Openings  are  provided  in  the  upper  portion,  by  means  of  which 
it  may  be  secured  to  the  body.  The  lower  portion  is  provided  with  a  cross- 
bar, in  the  form  of  a  foot-piece,  that  not  only  serves  to  keep  the  heel  from 
resting  on  the  bed  or  mattress,  but  serves  to  prevent  rotation.  Usually 
the  foot-piece  is  attached  by  a  bolt  and  nut  that  may  be  moved  backward 
and  forward  in  the  slot  by  means  of  a  small  screw  placed  in  the  end  of  the 
instrument.  By  attaching  a  perineal  band  to  the  splint,  a  proper  degree  of 
suspension  may  be  secured.  If  preferred,  however,  the  splint  may  be 
attached  to  a  cord,  weight  and  pulley,  as  are  many  other  patterns. 


Figure  2264.    Macwhinnie's  Extension  Apparatus. 

Macwhinnie's  Extension  Apparatus,  as  exhibited  in  figure  2264,  consists 
of  a  long  bar  extending  from  the  axilla  to  below  the  foot,  padded  on  the 
instep  and  supplied  with  a  wing  or  side  extension,  which,  when  attached 
to  the  lower  border,  prevents  rotation  of  the  appliance.  A  perineal  pad 
secures  extension.  Traction  may  be  secured  directly  in  the  long  axis  of 
the  limb  with  adhesive  straps  and  a  rack  and  pinion  placed  near  the  lower 
end  of  the  instrument.  After  the  bandages  are  secured  to  the  limb,  any 
degree  of  traction  may  be  obtained  by  means  of  a  key.  The  apparatus 
may  be  employed  not  only  in  fractures  but  diseases  of  the  hip-joint,  par- 
tial ankylosis  of  the  knee,  muscular  contraction  of  the  knee,  etc.  It 


SPLINTS. 


935 


keeps  the  heel  raised  from  the  bed,  permits  a  certain  amount  of  motion 
without  danger  of  displacement,  and  avoids  the  use  of  pulleys,  weights, 
ropes,  etc. 

Extension  Apparatus  is  frequently  required  in  the  treatment  of  this 
class  of  fractures.  While  these  appliances  may  be  purchased  from  surgical 
instrument  dealers,  a  plain  pulley  and  cord  and  a  pail  or  bag  of  sand  or 
similar  material  may  be  used  to  advantage. 


Figure  2265.    Levis' Extension  Apparatus.  Figure  2266.    Clark's  Suspension  Apparatus. 

Levis'  Extension  Apparatus,  as  exhibited  in  figure  2265,  comprises  an 
adjustable  upright  bar  supporting  a  pulley  in  its  upper  end,  a  clamp,  cord 
and  set  of  weights.  By  means  of  the  clamp,  the  bar  may  be  attached  to 
almost  any  form  of  bed-rail,  the  back  of  a  chair,  the  end  of  a  table  or  any 
object  of  sufficient  security  or  steadiness.  The  bar  is  in  bayonet  form  in 
its  upper  third  that  it  may  project  beyond  the  bed-rail.  The  weights  are 
easily  adjusted  to  the  hook  and  rod,  so  that  any  desired  number  may  be 
used.  The  apparatus  is  supplied  with  a  foot-block  and  cord,  so  that  when 
purchased,  it  is  complete  and  ready  for  use. 

Splints  for  General  Use  in  Fractures  and  Resections  of  the  Legf. 

Clark's  Suspension  Apparatus,  as  displayed  in  figure  2266,  comprises 
two  lateral  rods  (one  partially  flexed)  that  conform  to  the  shape  of  the  leg. 
The  bars  are  attached  to  a  foot-piece  at  their  extremities,  and  are  main- 
tained apart  at  a  proper  distance  by  a  bow- piece  over  the  limb.  The  latter 


Figure  2267.     Hodgen's  Suspension 
Apparatus. 


Figure  2268.    Lee's  Extension  Apparatus. 


is  supported  between  the  bars  by  means  of  wide  bandages  that  pass  under 
the  limb,  and  are  attached  to  a  bar  upon  either  side.  The  limb  is  sus- 
pended by  four  hooks,  from  which  cords  pass  over  a  sliding  pulley  that  is 
mounted  in  a  frame  arranged  for  supporting  the  splint  and  limb.  This 
frame  is  of  metal,  strongly  built,  and  provided  with  an  upper  central  bar 


936 


FRACTURES. 


along  which  a  pulley  moves  back  and  forth.  By  means  of  an  upright 
attached  to  the  foot  of  the  bed,  a  bag  of  sand  or  other  weight  may  be  used 
to  secure  extension. 

Hodgen's  Suspension  Apparatus,  as  exhibited  in  figure  2267,  comprises 
a  straight  wire  frame,  similar  in  construction  to  the  pattern  previously 
described.  Strips  of  wire  gauze  form  the  lower  portion  of  the  splint,  while 
strong  bows  of  iron  hold  the  lateral  bars  apart.  They  are  so  arranged 
that  they  may  be  removed  without  disturbing  the  dressings.  By  means  of 
a  foot-piece,  extension  may  be  secured  by  adhesive  plaster.  The  whole 
apparatus  is  arranged  to  be  suspended  from  the  ceiling,  wall  or  other 
convenient  place. 

Lee's  Extension  and  Suspension  Apparatus,  as  outlined  in  figure  2268, 
consists  of  a  perforated  metallic  splint  and  foot-piece,  extending  over  the 
posterior  surface  of  the  leg.  By  means  of  two  metallic  straps  with  hooks, 
cords  and  pulley,  suspension  from  ceiling  or  other  point  is  secured.  A 
Levis  apparatus,  as  previously  described  in  figure  2265,  secures  extension. 
As  the  foot-piece  is  separable,  the  appliance  may  be  used  with  or  without  it. 


Figure  2269.    Metallic  Doable-Inclined  Plane. 

The  Metallic  Double-Inclined  Plane,  shown  by  figure  2269,  consists  of  a  full 
length  posterior  leg  splint,  provided  with  a  hinge  opposite  the  knee-joint. 
By  means  of  extensions,  the  upper  and  lower  sections  may  be  changed  to 
fit  almost  any  case.  A  foot-piece  arranged  at  a  proper  angle  assists  in 
securing  comfort.  This  appliance  rests  upon  an  extension  board  that  is 
provided  at  its  outer  end  with  a  cross-bar  by  which  rotation  is  avoided.  A 
pin  placed  in  the  heel  of  the  splint  and  a  plate  provided  with  perforations 
at  regular  intervals  permit  any  degree  of  flexion  that  may  be  desired. 

Splints  for  Use  in  and  about  the  Knee-Joint. 


Figure  2270.    Anterior  and  Posterior  Knee  Splints. 

The  Anterior  and  Posterior  Knee  Splints,  shown  in  figure  2270,  are 
applicable  for  certain  classes  of  injuries  in  and  about  the  knee-joint.  They 
differ  from  each  other  only  in  that  one  is  anterior  and  the  other  posterior. 

Splints  for  Fractures  of  the  Leg. 

The  Anterior  and  Posterior  Splints  for  fractures  of  the  leg,  as  exhibited 
in  figure  2271,  differ  from  each  other  only  in  the  side  of  the  limb  upon 
which  they  are  to  be  used. 


SPLINTS. 


937 


The  Lateral  Splint,  shown  by  figure  2272,  differs  from  those  last  described 
in  being  constructed  for  use  on  the  lateral  aspect  of  the  limb.  They  may 
be  obtained  either  rights  or  lefts. 


Figure  2271.     Anterior  and  Posterior  Splints  for  Fractures  of  the  Leg. 

Meachem's   Leg   Splint,  as  exhibited  in  figure  2273,   is   applicable    not 
only  in  injuries  of  the  leg,  but  of  the  ankle  and  foot  as  well.     Its  inventor 


Figure  2272.     Lateral  Splint  for  the  Leg. 


Figure  2273.     Meachem's  Splint  for  Fractures 
of  the  Leg  and  Ankle. 


claims  that  it  possesses  all  the  advantages  and  none  of  the  disadvantages  of 
a  plaster  cast.  It  is  light  and  permits  of  examinations  without  danger  of 
displacement. 


Figure  2274.    Volkmann's  Sliding  Rest. 


Figure  2275.     Fracture  Box. 


Volkmann's  Sliding  Rest,  as  pictured  in  figure  2274,  consists  of  an  oblong 
frame,  the  upper  surface  of  which  is  in  the  form  of  a  'double  track,  along 
which  a  frame  used  to  support  the  leg  may  slide  back  and  forth.  This 
frame  presents  a  concave  upper  surface,  fitting  the  calf  of  the  injured  limb. 
A  foot-piece  placed  at  a  slightly  obtuse  angle  may  be  used  to  prevent  rota- 
tion. A  perforation  in  the  outer  end  of  the  sliding  board  accommodates 
the  projecting  heel. 

The  Fracture  Box,  portrayed  in  figure  2275,  consists  of  a  bottom,  a  foot- 
piece,  and  two  movable  side-pieces.  This  may  be  placed  upon  a  pillow  or 
box  to  give  it  a  slight  elevation.  If  any  extension  is  needed,  it  may  be 
secured  by  a  bandage  passed  around  the  ankle  and  the  foot,  and  through 
holes  in  the  foot-piece.  In  fixing  the  leg  in  this  fracture  box,  the  sides  are 
turned  down,  a  thick  layer  of  cotton  or  some  soft  material  arranged  for  the 
leg  to  rest  upon,  and  shaped  to  fit  the  natural  contour  of  the  calf.  The 
sides  are  also  packed,  turned  into  position  and  fastened. 

Ununited  Fractures. 

The  treatment  of  ununited  fractures  may  be  either  operative  or  pallia- 
tive. The  former  usually  involves  fixation  by  silver  wire,  ivory  pegs  or 
steel  wire,  all  of  which  have  been  described  in  the  chapters  devoted  to 
Minor  Operative,  and  Bone  and  Joint  Surgery. 


938 


FRACTURES. 


Palliative  measures  may  include  some  form  of  retentive  apparatus  by 
which  it  is  sought  to  partially  restore  the  strength  lost  by  reason  of  the 
fracture. 


Figure  2276.    Smith's  Artificial  Arm  for 
Ununited  Fracture  of  the  Humerus. 


Figure  2277.    Smith's 
Artificial  Limb  for 
Ununited  Fracture 
of  the  Tibia. 


Figure  2278.    Smith's 
Artificial  Limb  for 
Ununited  Fracture 
of  the  Femur. 


Smith's  Artificial  Limbs,  for  ununited  fractures,  as  exhibited  in  figures 
2276,  2277  and  2278,  are  heavy  leather  sockets,  overlaid  with  steel  bars, 
the  latter  provided  with  joints  where  necessary  to  secure  motion.  These 
sockets  should  be  carefully  molded  to  the  limb  and  supported  by  external 
buckles  or  lacing  devices,  that  perfect  attachment  may  be  secured. 


CHAPTER  XXXVII. 


ORTHOPEDIC  SURGERY. 

The  prevention  and  correction  of  physical  deformities,  whether  bone 
distortion  or  joint  function,  congenital  or  acquired,  is  largely  mechanical, 
necessitating  the  use  of  some  form  of  apparatus  by  which  the  surgeon 
seeks  to  restore  the  affected  parts  to  a  normal  condition  of  usefulness. 

We  use  the  word  "surgeon"  because,  in  our  opinion,  the  physician  who 
gives  no  more  attention  to  the  selection,  fitting  and  future  adjustment  of 
braces  than  to  send  his  patients  to  an  instrument  maker  for  treatment, 
can  not  expect  to  receive  beneficial  results.  The  dealer,  as  a  rule,  in  such 
cases,  either  selects  some  stereotyped  form  of  apparatus  or  the  one  that  will 
pay  him  the  best  profit. 

The  theory  that  the  average  instrument  maker  knows,  or  should  know, 
more  concerning  the  treatment  of  deformities  than  the  surgeon  is  false, 
and  the  sooner  it  is  exploded  and  such  cases  referred  to  those  who  under- 
stand and  give  close  attention  to  mechanical  therapy,  the  better  it  will  be 
for  suffering  humanity. 

Commercial  instrument  makers  should  not  pose  as  orthopedists,  even  if 
willing  to  be  held  responsible  for  the  results  of  their  work.  With  their 
scant  knowledge  of  anatomy  and  pathology,  and  without  opportunity  to 
watch  the  progress  of  cases,  they  should  be  expected  only  to  carry  out  the 
ideas  of  the  surgeon,  and  these,  too,  when  explicitly  specified. 

The  variety  of  appliances  that  has  been  devised  to  fill  the  requirements 
of  this  branch  of  surgery  is  almost  numberless,  and  it  is  to  be  regretted 
that  a  large  percentage  of  these  are  of  no  practical  value,  because,  either 
for  lack  of  correct  mechanical  principles  or  by  reason  of  poor  construction, 
they  do  not  meet  the  requirements. 

Braces  for  the  treatment  of  deformities  are  as  a  rule  too  complicated, 
heavy  and  cumbersome.  They  are  usually  the  creation  of  surgeons  who 
seek  to  construct  something  different  from  those  commonly  in  use,  either 
because  they  believe  their  ideas  to  be  an  improvement,  or  because  they 
wish  to  attach  their  names  as  inventors  to  some  form  of  apparatus.  Fre- 
quently the  selection  of  a  brace  is  left  to  the  instrument  maker,  who,  being 
desirous  of  showing  his  skill  as  a  workman  and  designer  of  complex 
mechanism,  and  knowing  he  can  secure  a  much  better  price  for  an  elab- 
orate and  finely  constructed  brace,  adds  all  the  bars,  pads,  springs,  joints, 
bands,  straps,  crutches,  etc.,  that  the  appliance  will  permit. 

In  the  selection  of  appliances  for  illustration  in  this  chapter,  we  shall 
choose  only  such  as  we  believe  represent  modern  types  of  improved 
apparatus,  such  as  are  employed  by  the  leading  specialists  for  treating  the 
more  common  cases  of  deformity. 

Many  appliances  are  illustrated  in  the  catalogues  of  surgical  instrument 
makers,  not  because  they  can  be  advantageously  employed,  but  for  the 
reason  that,  as  they  look  well  on  paper,  there  is  a  commercial  demand 
for  them. 

Surgeons,  as  a  rule,  are  too  prone  to  consult  the  price  lists  of  the  dealer 

939 


940  ORTHOPEDIC    SURGERY. 

rather  than  the  standard  text-books.  This  is  unfortunate,  because  the  result 
is  that  there  is  still  a  sale  for  apparatus,  which,  having  been  found  imper- 
fect or  impracticable,  was  discarded  by  the  better  class  of  practitioners 
years  ago.  As  long  as  there  is  a  demand,  no  matter  what  the  source,  for 
poorly-designed  braces,  the  instrument  maker  generally  must  either  fill 
such  orders  or  permit  them  to  go  to  his  competitors,  even  though  he 
believes  the  appliances  will  prove  of  little  value. 

As  errors  in  construction  are  often  due  to  improper  or  incomplete  meas- 
urements, we  urge  the  necessity  of  accurate  and  explicit  instructions  on  the 
part  of  the  surgeon. 

Apparatus  of  this  class  is  manufactured  only  to  order ;  consequently,  if 
unsatisfactory,  and  unless  the  physician  can  show  that  it  has  not  been 
constructed  in  accordance  with  his  specifications,  the  blame  should  not  be 
placed  on  the  maker. 

While  appliances  of  this  character  should  be  so  fitted  as  not  to  cause 
pain  or  annoyance,  still  they  are  often  more  or  less  uncomfortable  when 
first  applied.  Patients  being  easily  discouraged  or  dissatisfied  with  trivial 
matters  at  such  times,  it  is  therefore  advisable  that  the  commercial  transac- 
tion in  securing  a  brace  should  be  between  the  patient  and  the  instrument 
maker.  If,  however,  the  surgeon  assumes  the  responsibility  of  payment, 
he  should,  as  a  matter  of  protection,  collect  the  cost  of  the  apparatus  from 
his  patient  in  advance. 

That  a  uniform  system  of  ordering  may  be  adopted,  we  insert  a  diagram 
for  orthopedic  measurements.  When  possible,  the  surgeon  will  find  it  more 
satisfactory  to  make  a  drawing  upon  which  are  carefully  noted  all  marks 
and  measurements  as  to  bars,  braces,  pads,  junctions,  joints,  straps,  buck- 
les, etc.,  giving  outlines  in  full. 

We  believe  all  specialists  will  agree  that  while  instrument  makers  fur- 
nish what  appear  to  be  full  instructions  for  measurements  and  ordering, 
the  appliances  furnished  by  them  frequently  come  far  from  either  fitting 
properly  or  meeting  required  conditions.  This  is  largely  due  to  the  fact 
that  the  workman  does  not  see  the  patient  or  fit  the  various  pieces  to  him. 

Parts  to  be  padded  are  often  left  uncovered,  while  curves  and  protuber- 
ances are  not  fitted.  All  this  shows  the  necessity  for  carefully  giving  all 
details  and  whenever  possible  furnishing  a  sketch  of  the  appliance  wanted. 

Braces  for  legs  and  arms  should  be  traced  full  size  on  paper,  the  posi- 
tion of  joints,  pads,  plates,  bands,  etc.,  being  carefully  marked.  When 
shoes  are  to  be  worn,  they  should,  excepting  when  special  ones  are  con- 
structed for  club-feet,  be  furnished  by  the  patient,  for  it  is  difficult  to 
secure  well- fitting  shoes  from  the  measurements  that  usually  accompany 
orders  for  deformity  apparatus 

Measurements  either  for  description  in  the  construction  of  braces  or  for 
purposes  of  comparison  may  require  the  use  of  various  appliances  depend- 
ing much  on  the  location  and  nature  of  the  deformity  and  the  degree  of 
accuracy  desired.  The  instruments  usually  employed  consist  of  tape 
measures,  goniometers  and  epipedometers. 

The  Goniometer,  as  shown  in  figure  2280,  is  employed  in  measuring 
lateral  curvatures,  adduction  and  abduction  in  hip  joint  disease,  the  angle 
of  an  ankylosed  joint,  etc.  It  consists  of  two  straight  slotted  arms  pivoted 
together  in  such  a  manner  that  a  right  angle  or  any  angle  of  obliquity  may 
be  accurately  measured  and  noted.  A  graduated  dial  in  semi- circular  form 
attached  to  the  horizontal  arm  always  shows  the  angle  sustained  by  one  to 
the  other  of  the  two  arms.  In  cases  of  lateral  curvature,  the  cross  or  hor- 


ORTHOPEDIC    MEASUREMENTS. 


941 


izontal  bar  may  be  placed  on  a  level  with  the  axillae  and  the  perpendicular 
bar  made  to  conform  to  the  direction  of  the  spine  as  shown  by  a  line  drawn 
from  the  sacro-lumbar  articulation  to  the  vertebra  prominens. 

In  cases  of  hip-joint  disease,  the  horizontal  arm  is  placed  on  a  line  with 

Explanation  of  Letters  and  Figures. 

A.  Ball  of  Foot. 

B.  Instep. 

C.  Above  Ankle. 

D.  Calf. 

E.  Upper  Calf. 

F.  Knee. 

G.  Above  Knee. 

H.  Upper  Third  of  Thigh. 

I.  Thigh  at  Perineum. 

K.  Trochanter  Major. 

L.  Circumference  at  Pelvis 

M.  "  at  Umbilicus. 

N.  Forearm  above  Wrist. 

0.  Wrist. 

P.  Circumference  ot  Hand. 

Q.  Arm  above  Elbow. 

R.        "at  Elbow. 

S.  Upper  Forearm. 

T.  Middle 

U.  Circumference  of  Chest. 

V.  Circumference  under  Axilla  and  over 

Shoulder. 

W.  Upper  Arm. 

X.  Circumference  of  Waist. 

Y.  Lower  Third  of  Thigh. 

Z.  Circumference  of  Heel  and  Instep. 

1.  Sole  of  Foot 

2  to  3.  Length  of  Foot. 

4.  Sacro-lumbar  Articulation. 

5.  First  Vertebra  involved  (in  sketch). 

6.  Last          "  "  (     "     ) 
7-7.  Centers  of  Scapulae. 

8-8.         Axillae. 

9.  Crest  of  Ilium. 

10  to  ii  Extent  of  curvature. 

12.  Circumference  of  Head. 

13.  Vertebra  Prominens 
Base  of  Skull. 

Leg  below  Calf. 
Ankle. 


14. 
15- 

1 6. 


Figure  2279.     Diagram  for  Orthopedic  Measurements. 


Measurements  for  Shoes. 


Trace  outline  of  Foot  on  Paper.  6. 

Length  of  Foot  (2  to  3)  7 

Circumference  above  Ankle.  8. 

"                at        "  9 

of  Heel  and  Instep.  (Z). 


Circumference  at  B. 

"     A.    . 

"  Base  of  Little  Toe. 
State  if  for  Right,  Left,  or  both  Feet. 


942 


ORTHOPEDIC    SURGERY. 


the  anterior  superior  iliac  spines  and  the  vertical  on  a  line  with  the  center 
of  the  leg  of  the  affected  side. 

The  treatment  of  deformities,  so  far  as  it  lies  in  the  scope  of  this  work, 
may  be  mechanical  or  operative,  while  in  a  few  cases  osteoclasis  may  be 
necessary. 


Figure  2280.    Goniometer. 

The  mechanical  correction  and  prevention  of  deformities  will  occupy 
almost  the  entire  chapter,  for  it  is  with  this  that  we  have  principally  to 
deal.  Operative  measures  will  be  found  included  in  the  chapters  on  Minor, 
and  Bone  and  Joint  Surgery. 


MECHANICAL  FRACTURE. 

The  instruments  employed  to  produce  intentional  fracture  are  called 
osteoclasts,  and  the  operation  is  frequently  known  as  osteoclasis.  It  is 
employed  for  the  purpose  of  straightening  bow- legs  and  other  deformities. 

Osteoclasts. 

These  usually  consist  of  a  pressure  pad  and  two  points  of  counter-pres- 
sure, with  force  for  producing  fracture  of  any  engaged  bone.  If  for  bow- 
leg,  the  force  is  directed  against  the  point  of  greatest  convexity.  Their  use 
is  followed  by  treating  the  fracture  in  the  usual  manner. 

Rizzoli's  Osteoclast,  as  it  appears  in  figure  2281,  consists  of  a  bar  of 
steel  i  inch  in  width  by  y%  of  an  inch  in  thickness,  excepting  in  the  center 
where  this  is  increased  to  give  strength  for  an  opening  through  which 
passes  a  forcing-screw.  This  screw  is  supplied  with  a  bow-shaped  pad, 
formed  like  a  crutch-top  with  the  concave  surface  facing  downward.  It  is 
of  round  iron  ^  an  inch  in  diameter,  padded  and  attached  to  a  screw  with 
a  swivel  joint. 


OSTEOCLASIS. 


943 


The  upper  end  of  the  screw  is  supplied  with  a  strong  handle  by  which 
it  is  operated.  Counter-pressure  is  supplied  by  heavy  oval  rings  arranged 
to  slide  along  the  bar,  fixation  being  secured  at  any  point  by  thumb-screws. 
The  inner  surfaces  of  these  rings  are  also  padded. 


Figure  2281.     Rizzoli's  Osteoclast. 


Figure  2282.    Grattan's  Osteoclast. 


Grattan's  Osteoclast,  as  portrayed  in  figure  2282,  comprises  two  curved 
forks  attached  to  a  hinged  joint  and  arranged  that  they  may  be  set  at  any 
desired  point  of  convergence.  The  proximal  ends  of  the  arms  are  curved 
upward,  the  inner  borders  furnishing  points  for  counter-pressure.  The 
joint  is  supplied  with  a  head  through  which  passes  a  forcing  screw,  the 
latter  terminating  in  a  contact-bar  by  which  direct  pressure  is  applied. 
This  instrument  may  be  readily  detached  from  the  fractured  limb  without 
displacement  of  the  broken  bones. 


Figure  2283.     Ridlon's  Osteoclast. 

Ridlon's  Osteoclast,  as  outlined  in  figure  2283,  consists  of  two  strong 
counter-pressure  hooks  with  a  central  forcing-bar  resembling  in  some 
degree  the  patterns  previously  described.  The  former  are  attached  to  a 
cross-bar  provided  with  a  slot  and  mechanism,  by  means  of  which  the  arms 
may  be  separated  to  any  desired  extent.  The  forcing-bar  is  operated  by  a 


944  ORTHOPEDIC    SURGERV. 

mechanism  powerful,  yet  easy  in  manipulation.  The  lateral  surfaces  of 
the  shaft  of  the  forcing-bar  are  provided  with  cogs  that  contact  with  cog 
wheels  one  upon  either  side.  These  wheels  are  operated  by  long  levers 
attached  to  the  shaft  of  each,  contact  being  secured  by  sliding  dogs  attached 
to  the  handles.  After  the  instrument  is  adjusted  to  the  limb,  inward 
pressure  upon  the  handles  will  readily  produce  a  fracture.  This  instrument 
may  also  be  removed  without  displacing  the  ends  of  the  fractured  limb. 

Brace  "Wrenches. 

While  braces  are  usually  manufactured  from  steel,  the  latter  is  so  tem- 
pered that  it  will  admit  of  changes  in  form  and  shape  without  heating.  In 
many  instances  where  braces  are  ordered  and  found  upon  application  to  fit 
imperfectly,  they  may  be  changed  to  meet  the  requirements  by  the  aid  of 
a  pair  of  monkey  wrenches  or  similar  appliances.  Exceptions  to  this  rule 
are  limited.  As  Sayre  has  well  said,  "The  practitioner  should  adapt  the 
instrument  to  the  deformity  and  not  the  deformity  to  the  instrument,  as  is 
'too  frequently  attempted.  "  A  surgeon  should  not  hesitate,  when  he  receives 
a  brace  from  -an  instrument  dealer,  to  make  such  changes  in  shape  as  the 
case  demands.  Should  the  apparatus  be  broken  by  such  action,  the  maker 
should  replace  the  broken  part  without  cost.  These  changes  will  often 
obviate  long  delays  in  returning  braces  and  in  the  expense  of  shipments. 


Figure  2284.     Plain  Wrench  for  Figure  2285.     Triple  Action  Wrench. 

Bending  Braces. 

The  Plain  Wrench  for  Bending  Braces,  which  is  seen  in  figure  2284, 
may  be  obtained  in  pairs  and  of  any  length  desired.  Usually  they  will  not 
be  required  less  than  7  or  more  than  14  inches  in  length.  The  gripping 
slot  upon  each  end  should  be  of  different  widths.  The  wrench  generally 
found  in  the  hands  of  dealers  is  10  inches  in  length  and  is  suited  for  bars 
T5g-  of  an  inch  in  thickness. 

The  Triple  Action  Wrench,  as  illustrated  in  figure  2285,  is  so  con- 
structed that  the  fork  or  clamp  may  be  turned  either  to  the  right,  the 
left,  or  fixed  so  as  to  remain  stationary.  With  a  pair  of  these  wrenches, 
braces  usually  can  be  curved  or  bent  without  removing  them  from  the 
patient,  and  this  is  a  great  advantage  in  securing  accurate  adjustment. 

General  Arrangement. 

As  neither  the  pathology  nor  etiology  of  disease  is  a  proper  subject  for  dis- 
cussion in  this  work,  we  have  chosen  a  topographical  arrangement  for  this 
chapter,  considering  the  head,  trunk,  upper  extremities,  hips,  lower 
extremities,  etc. ,  in  rotation  without  regard  to  the  cause  of  the  diseased 
condition. 

We  assume  that  the  treatment  selected  for  each  case  is  to  be  mechanical 
or  operative,  else  this  volume  would  not  be  consulted  for  reference.  Unless 
the  operative  procedure  chosen  requires  special  apparatus  not  described  in 
the  chapters  devoted  to  Minor,  and  Bone  and  Joint  Surgery,  no  reference 
to  the  instruments  employed  will  be  made  in  this  section. 


TORTICOLLIS. 


945 


TORTICOLLIS. 

Mechanical  treatment,  unless  it  follows  operative  interference,  is  usually 
unsatisfactory.  After  tenotomy  or  a  similar  surgical  procedure,  and  in 
some  paralytic  cases,  the  employment  of  a  suitable  retention  apparatus  is 
indicated. 

In  the  construction  of  appliances  for  this  deformity,  the  trunk  is  used  as 
a  base  from  which  to  obtain  fixation  that  counter-rotation  or  retention  of 
the  head  may  be  obtained.  An  elastic  force  is  usually  employed  to  make 
constant  traction  in  the  normal  direction  or  away  from  that  toward  which 
the  head  is  inclined,  thus  substituting  an  artificial  muscle  for  the  natural 
one  in  which  the  power  has  been  lost. 


Figure  2286.    Post's  Torticollis  Brace. 


Figure  2287.    Davis'  Torticollis  Brace. 


Post's  Torticollis  Brace,  as  portrayed  in  figure  2286,  represents  one  of 
the  simplest  forms  of  this  class  of  appliances.  It  is  intended  more  for  direct 
traction  than  for  counter-rotation,  although  some  degree  of  the  latter  may 
be  obtained.  It  consists  of  a  firm  wide  band  encircling  the  trunk  under 
the  axillae.  This  may  be  made  from  cloth,  leather,  or  if  cost  is  a  consider- 
ation, from  plaster  <  of  paris.  The  head  is  clamped  by  three  non-elastic 
bands,  one  encircling  it  horizontally,  a  second  passing  over  the  top  trans- 
versely and  a  third  antero-posteriorly,  all  being  united  by  stitches  at  crossing 
points.  This  system  of  head-bands  is  attached  to  the  trunk  belt  by  an 
elastic  band  or  cord  with  a  chain  so  adjusted  that  any  degree  of  traction  in 
the  necessary  direction  may  be  obtained. 

Davis'  Apparatus  for  Torticollis,  as  shown  in  figure  2287,  consists  of  a 
steel  bow  passing  over  the  head,  the  lower  ends  of  which  rest  upon  a 
shoulder  collar  that  may  be  of  such  size  and  material  as  is  best  adapted  for 
the  amount  of  weight  to  be  supported.  The  bow  should  be  of  sufficient 

60 


946 


ORTHOPEDIC    SURGERY. 


size  as  to  leave  a  space  about  two  inches  between  it  and  the  border  of  the 
head.  The  lower  ends  should  be  forked,  one  prong  passing  in  front,  the 
other  behind,  to  a  sufficient  distance  to  allow  of  firm  connection  with  the 
collar.  The  latter  should  be  preferably  of  steel  that  the  pressure  may  be 
distributed  over  a  considerable  surface.  It  may  be  well  padded,  covered 
with  leather,  and  the  two  faces  united  by  a  strap  and  buckle.  Axillary 
straps  may  be  employed  to  hold  it  firmly  in  place.  The  head  may  be 
secured  by  any  form  of  elastic  support  and  fastened  to  the  upright  bow  by  a 
strap  and  buckle. 


Figure  22S8.    Reynders'  Apparatus  for  Torticollis. 


Reynders'  Apparatus  for  Torticollis,  as  illustrated  in  figure  2288,  con- 
sists of  a  pelvic  band  with  upright,  crutches,  clavicular  cross-piece  and 
shoulder  straps,  much  after  the  pattern  of  many  spinal  braces,  the  whole 
being  firmty  fixed  to  the  trunk.  The  head  is  securely  held  by  means  of  a 
wide,  sheet-steel  band  which  encircles  it  in  a  horizontal  plane,  posteriorly 
from  eye  to  eye.  This  is  held  in  place  by  straps  over  the  forehead  and  under 
the  chin.  Lateral  openings  are  provided  through  which  the  ears  may  pro- 
trude. The  upright  is  attached  to  the  head-piece  by  two  joints,  each  con- 
trolled by  a  key  so  that  fixation  in  any  direction  may  be  secured  and  per- 
manently maintained.  After  the  brace  and  head-piece  are  in  position  and 
the  joints  firmly  secured,  extension  may  be  obtained  by  means  of  a  sliding 
arrangement  regulated  by  a  thumb-screw,  something  after  the  pattern  of 
many  hip  braces.  This  provides  means  for  extension  to  any  desired  degree, 
and  a  position  that  may  be  gradually  changed. 


POTT'S  DISEASE.  947 


TUBERCULAR    OSTEITIS    OF     THE    SPINE— SPONDYLITIS— 

ANTERO-POSTERIOR  CURVATURE  OR 

POTT'S  DISEASE. 

Treatment  for  this  deformity  is  usually  directed  to  relieve  the  affected 
vertebrae  from  pressure,  whether  due  to  super-incumbent  weight,  jar  or 
bending  of  the  spinal  column.  The  methods  generally  employed  are :  fix- 
ation, with  or  without  leverage,  suspension  or  traction,  and  recumbency, 
to  secure  rest. 

Fixation. 

This  may  be  secured  by  braces  and  jackets. 

Braces  for  Pott's  Disease. 

Braces  for  the  treatment  of  antero-posterior  curvature  usually  consist  of 
metallic  levers,  acting  on  the  transverse  processes  of  the  vertebrae  in  such 
manner  as  to  compensate  by  lateral  force  for  the  weight  of  the  superim- 
posed parts.  They  are  employed  to  reduce  inter-vertebral  pressure  on  the 
affected  vertebrae.  They  are  so  constructed  that  the  diseased  vertebrae  con- 
stitute the  fulcrum,  the  weight  and  power  being  represented  by  counter- 
pressure  bands  or  clamps.  If  for  cases  involving  the  seventh  dorsal  vertebra 
or  any  above  it,  they  should  usually  be  constructed  with  some  form  of  a  sup- 
port for  the  head. 

Braces  admit  of  easy  examination  of  the  back,  and  the  degree  and  direc- 
tion of  pressure  may  be  changed  from  time  to  time  as  required.  The  adjust- 
ment of  their  mechanism  is  easily  regulated,  and  the  relative  positions  of  the 
pads  and  affected  parts  changed  when  necessary.  When  applied  with  skill 
and  thoroughness,  they  form  the  most  efficient  means  for  the  treatment  of 
this  class  of  deformities. 

The  only  disadvantages  urged  against  their  use  are  that  patients  some- 
times take  occasion  either  to  remove  them  entirely  or  to  reduce  the  pressure 
on  the  diseased  vertebrae,  and  that  they  require  considerable  skill  in  their 
application  and  management.  The  latter  argument  is  practically  without 
force,  because  a  surgeon  who  is  not  qualified  to  properly  apply  and  manage 
a  spinal  brace,  should  not  undertake  the  treatment  of  a  case.  Their  con- 
struction should  involve  great  care  because  good  results  can  be  obtained  only 
by  minute  attention  to  details. 

Badly  designed  and  poorly-fitting  spinal  braces  are  responsible  for  much 
of  the  ill-repute  into  which  this  class  of  apparatus  has  fallen.  Methods  and 
means  are  judged  by  comparison.  Plaster  jackets  have  been  applied  by 
surgeons  as  a  rule  during  suspension,  and  generally  furnish  immediate 
relief,  the  surgeon  caring  for  and  watching  over  the  case  often  for  months 
or  years  following. 

Braces  which  are  often  made  with  stiff  hip-bands,  strong  unremitting 
springs  with  insufficient  and  improperly  placed  pads,  applied  without  suspen- 
sion, frequently  by  unskilled  hands  and  even  by  physicians  or  workmen  who 
perhaps  may  never  see  the  case  again,  do  not  and  can  not  give  satisfaction, 
particularly  when,  as  is  often  the  case,  the  physician  and  patient  believe 
that  the  purchase  and  application  of  a  brace  is  all  that  is  necessary  to  effect 
a  cure. 

While  good  workmanship  is  essential  in  the  construction  of  spinal  braces, 
nicety  of  finish  is  not  necessary.  Accuracy  of  fit  is  all  important,  because 


948  ORTHOPEDIC    SURGERY. 

even  minute  errors  give  rise  to  pain  and  discomfort,  frequently  to  such  an 
extent  that  the  apparatus  can  not  be  worn. 

The  material  used  in  manufacture  is  generally  untempered  steel. 
While  extra  weight  and  unnecessary  strength  must  be  avoided,  care  must  be 
exercised  in  selecting  material  particularly  for  the  upright  bars,  that  they 
may  be  of  such  strength  as  not  to  give  way  under  pressure,  as,  under  no 
circumstances,  should  a  brace  permit  bending  of  the  spine  at  the  diseased 
point. 

Pads  may  be  made  from  leather  stuffed  with  felt  or  layers  of  soft  flan- 
nel, or  plate's  may  be  manufactured  from  hard  rubber  or  wood  accurately 
fitted  to  the  external  surfaces  upon  which  they  are  to  rest.  Those  employed 
for  the  vertebrae  should  rest  as  close  together  as  is  possible  without  pro- 
ducing pressure  on  the  spineous  processes. 

Covers  may  be  of  soft  leather  such  as  kid,  or  chamois,  or  the  bars  may 
be  covered  by  winding  strips  of  canton  or  woolen  flannel  around  them. 
Buckles  should  be  of  some  patent  variety,  those  without  teeth  being 
preferred.  Straps  should  be  non-elastic. 

Pelvic  bands  are  a  frequent  source  of  annoyance  and  discomfort  because 
of  faulty  construction.  Many  of  the  old-style  braces  and  some  of  the  later 
ones,  are  manufactured  with  a  plain  steel  band  encircling  the  hips.  This 
not  only  fails  to  fit  closely  to  the  contour  of  the  parts,  but  in  order  to  avoid 
the  appearance  of  clumsiness,  it  is  frequently  manufactured  from  material 
too  light  to  be  of  value.  It  is  evident  that  steel  was  first  selected  for  this 
use  because  it  furnished  a  base  firm  enough  for  crutch-extension.  As  the 
latter  can  be  secured  only  with  dome-shaped  bands,  resting  on  flaring  or 
sloping  hips,  steel  is  applicable  only  to  such  cases  as  furnish  the  necessary 
bearing  surface.  As  crutches  are  not  often  advised  in  the  more  modern 
patterns,  there  seems  no  longer  to  be  any  reason  for  the  use  of  a  steel  band 
completely  encircling  the  pelvis.  Leather  when  used  for  this  purpose  is 
soft  and  flexible,  far  more  comfortable,  and  can  be  so  constructed  as  to 
furnish  a  reliable  support.  Such  bands  should  be  manufactured  from 
heavy  leather,  3  to  4  inches  in  width.  They  may  be  accurately  fitted  by 
soaking  the  leather  in  water  until  soft,  then  applying  it  to  the  patient,  pass- 
ing the  band  around  the  hips,  so  that  its  upper  margin  will  be  fully  an 
inch  above  the  iliac  crests,  where  it  should  be  secured  and  carefully  molded 
to  the  parts.  By  removing  V-shaped  pieces  from  the  upper  margin,  a 
contraction  of  this  border  may  be  secured  until  a  close  and  accurate  fit  is 
obtained.  The  cut  edges  may  then  be  stitched  together  or  roller  bandages 
may  be  applied  in  such  a  manner  as  to  hold  the  leather  firmly  in  place  until 
dry.  If  applied  at  night,  the  leather  will  be  in  proper  shape  for  removal  on 
the  following  morning,  when  the  seams  may  be  carefully  stitched,  the  band 
attached  to  the  uprights  of  the  brace  by  a  short,  thin  steel  cross-bar  extend- 
ing upon  either  side  as  far  as  the  post-trochanteric  sulcus.  If  this  band  be 
found  too  wide  in  front,  it  may  be  reduced  to  about  2  inches. 

Crutches,  as  ordinarily  applied,  are  of  doubtful  utility.  The  supposed 
object  of  the  crutch  is  to  secure  suspension  and  with  it  a  certain  degree  of 
extension.  In  extensive  cases,  in  which  several  vertebrae  are  involved, 
particularly  during  the  progressive  stage,  they  should  prove  of  value  when 
properly  applied.  This  can  only  be  obtained  by  a  close-fitting  hip-band 
encircling  the  trunk  and  resting  on  the  iliac  crests.  If  a  sufficient  degree 
of  suspension  to  be  of  value  as  a  traction  agent  is  secured,  the  brace  is 
usually  too  uncomfortable  to  be  worn.  It  also  interferes  with  the  circula- 
tion of  the  blood  in  the  arms,  but  without  such  a  force  a  crutch  is  useless. 


POTT'S  DISEASE.  949 

The  writer  has  observed  braces  constructed  with  crutches  for  patients  where 
it  was  found  necessary  to  employ  shoulder  straps  to  prevent  the  apparatus 
from  slipping  too  far  down  upon  the  pelvis.  Comment  as  to  the  value  of 
such  braces  is  unnecessary. 

The  amount  of  pressure  to  be  made  on  the  spinous  processes  must 
depend  somewhat  on  the  nature  of  the  case,  but  under  all  circumstances 
it  should  be  limited  to  the  amount  that  can  be  sustained  by  the  skin  with- 
out impairing  its  integrity.  Care  must  be  exercised  to  see  that  counter- 
pressure  is  secured  at  top  and  bottom.  The  latter  may  usually  be  obtained 
with  some  form  of  a  pelvic  band,  while  the  former  can  be  arranged  with 
shoulder  straps,  breast- aprons,  etc.  By  such  means  the  braces  should  be 
carefully  fixed  to  the  trunk,  in  which  condition  they  should  remain  while 
being  worn,  whether  continuously  or  only  throughout  the  day,  as  advised 
by  some  authorities.  All  agree,  however,  that  under  no  circumstances, 
should  a  patient  sit  upright  unless  the  brace  be  properly  applied. 

Measurements. 

As  accurate  adjustment  is  necessary,  all  measurements  should  be 
explicit  and  should  include  a  full-sized  tracing  along  the  line  of  the  trans- 
verse processes  showing  the  exact  shape  of  the  spinal  column  from  the 
sacro-lumbar  articulation  to  the  vertebra  prominens,  and  if  the  brace  is  to 
be  constructed  with  a  jury  mast,  the  tracing  should  be  continued  to  include 
the  neck  and  top  of  the  head. 


Figure  2289.     Illustrating  manner  of  securing  an  accurate  form  for  tracing. 

Figure  2289  exhibits  a  common  method  of  securing  a  correct  tracing  of 
the  spinal  column.  The  patient,  lying  prone,  is  fitted  with  a  strip  of  lead 
or  a  combination  of  lead  and  zinc  closely  molded  to  the  spine,  after  which 
the  outline  is  to  be  traced  full  sized  on  a  sheet  of  paper.  For  future  refer- 
ence both  for  comparative  diagnosis,  and  in  case  of  a  misfit  on  the  part  of 
the  instrument  maker,  the  surgeon  should  keep  a  duplicate  tracing. 

Young's  Spinal  Curve  Tracer,  as  displayed  by  figure  2290,  consists  of  a 
hard  wood  strip  2  to  2^/2  inches  in  width  and  22%  inches  in  length,  sup- 
plied with  a  slot  y^  of  an  inch  wide  extending  for  20  inches  through  its  long 
diameter.  In  this  slot  a  series  of  pins  and  posts  is  provided,  each  3/%  by 
24  of  an  inch,  arranged  loosely  enough  to  play  freely  up  and  down,  small 
brass  nails  at  each  end  preventing  them  from  dropping  out  of  the  frame. 
As  the  series  of  pins  exactly  fills  the  frame,  they  may  be  held  firmly  in  any 
desired  position  by  tightening  a  thumb-screw  placed  at  one  end  and 
arranged  for  this  purpose. 

A  tracing  of  the  spine  may  be  secured  by  placing  the  apparatus  along 
the  line  on  which  the  tracing  is  to  be  made,  loosening  the  thumb-screw 


950 


ORTHOPEDIC    SURGERY. 


and  allowing  the  pins  to  drop  upon  the  skin.  That  the  line  may  be  perfect, 
each  should  be  tapped  consecutively  that  a  perfect  fit  may  be  obtained. 
When  all  are  in  position,  the  thumb-screw  may  be  tightened,  and  the  appa- 
ratus removed.  It  may  then  be  laid  flat  on  a  piece  of  card-board  on  which 


Figure  2290.    Young's  Spinal  Curve  Tracer. 

the  outline  may  be  traced  around  the  ends  of  the  pins  with  a  pencil.  Of 
course  the  line  will  be  irregular,  presenting  a  series  of  small  scallops. 
With  a  pair  of  scissors  the  operator  may  follow  this  line,  cutting  through 
the  highest  or  most  prominent  part  of  each  scallop,  thus  obtaining  an 
accurate  tracing.  After  this  has  been  secured,  the  operator  should  place  it 
upon  the  spine  to  see  that  the  contour  of  the  latter  corresponds  with  the 
margin  of  the  cardboard.  The  inventor  has  suggested  that  aluminum  pins 
in  a  metallic  frame  be  used.  This  modification  would  furnish  a  light,  neat 
and  durable  apparatus.  This  appliance  will  be  found  particularly  valuable 


Figure  2291      Beeley's  Square  and  Plumb  Line. 

in  securing  transverse  tracings  in  cases  of  lateral  curvature  where  great 
accuracy  for  comparative  diagnosis  from  time  to  time  is  desirable.  The 
tracing  should  be  made  each  time  at  the  same  point  and  from  one  posterior 
axilla  to  the  other. 


POTT  S    DISEASE. 


951 


Beeley's  Square  and  Plumb  Line,  as  shown  in  figure  2291,  consists  of  a 
neck-band  with  buckle  with  a  tape  attached,  from  the  end  of  which  an  ad- 
justable plumb  weight  is  suspended.  By  means  of  a  small  plate  of  metal 
bent  at  a  right  angle,  and  arranged  as  shown  in  the  illustration,  the  amount 
of  anterior  curvature  or  deviation  in  scoliosis  may  be  determined. 

It  is  especially  valuable  where  notes  of  improvement  are  kept  of  cases 
under  treatment,  or  where  exercises  are  being  given  and  an  accurate  record 
is  kept  from  time  to  time. 


Figure  2293.    Taylor's  Brace  for  Pott's 
Disease. 


Figure  2293.      Rid  Ion's  Spinal  Brace  for 
Pott's  Disease. 


Taylor's  Brace  for  Pott's  Disease,  as  sketched  in  figure  2292,  furnishes 
one  of  the  most  desirable  patterns  for  the  treatment  of  antero-posterior 
curvature.  Its  general  form  is  satisfactory  because  modifications  and 
changes  can  be  easily  made.  It  consists  of  two  parallel  uprights  of  untem- 
pered  steel  extending  along  both  sides  of  the  spine  from  a  point  just  above 
the  posterior  superior  iliac  spines  to  the  first  dorsal  vertebra  where  they 
diverge  laterally,  forming  hook-shaped  clamps  that  pass  over  the  shoulder 
to  its  anterior  margin,  where  they  rest  close  to  the  roots  of  the  neck.  These 
lateral  extensions  serve  to  secure  permanent  antero-posterior  and  vertical 
fixation  of  the  apparatus. 

Each  upright  is  composed  of  three  pieces,  the  middle  one  forming  the 
pad-plate.  This  form  may  be  changed  to  a  single-piece  bar,  and  the  pads 
may  be  attached  by  pins  and  slots  or  changeable  screws.  The  strength  of 
these  uprights  must  of  course  vary  with  the  si&e,  condition  and  occupation 
of  the  patient.  Usually  bars  from  fa  to  J>4  an  inch  in  width  and  of  Nos. 


952 


ORTHOPEDIC    SURGERY. 


8  to  12  Brown  and  Sharp's  gauge  will  answer.  These  uprights  are  secured 
at  their  lower  ends  to  an  inverted  U-shaped  support,  the  branches  of 
which  terminate  in  pads  that  rest  in  the  post-trochanteric  sulcus  upon  each 
side,  the  pads  extending  as  low  on  the  buttocks  as  is  possible  without 
interfering  with  the  patient's  comfort  or  the  adjustment  of  the  brace  when 
in  a  sitting  posture. 

A  cross-bar  is  attached  to  the  uprights  at  points  opposite  the  axillae,  to 
which  the  apron  straps  are  secured.  The  bars  should  be  far  enough  apart 
to  rest  upon  the  transverse  processes  of  the  vertebrae  without  interfering 
with  or  pressing  on  the  spinous  processes.  They  should  be  curved  to  fit  a 
lead-bar  tracing  as  described  by  figure  2289.  Each  is  supplied  with  a 
hinged  pressure-pad  so  adjusted  that  modifications  of  position  and  pressure 
may  be  secured  as  desired.  The  pads  are  of  firm  material,  preferably  of 
hard  rubber,  although  in  certain  cases,  soft  elastic  pads  may  be  employed. 
The  ends  of  the  U-shaped  bar  are  supplied  with  hard  rubber  or  other 
suitable  pads,  thus  furnishing  an  accurately  fitting  and  enlarged  pressure 
surface. 

Counter-pressure  on  the  anterior  points  of  resistance  is  secured  by 
means  of  an  apron  and  two  triangular  pads  preferably  of  hard  rubber  placed 
against  the  chest  just  below  the  clavicles.  These  are  joined  by  a  stiff  bar 
bridging  but  not  touching  the  chest.  This  bar  should  be  adjustable  that 
the  padded  space  between  may  be  increased  or  diminished  as  desired. 
These  pads,  at  their  inner  and  upper  angles,  are  fastened  to  the  curved 
ends  of  the  posterior  upright  bars  by  straps  and  buckles.  The  lower  angles 
of  the  pads  are  secured  to  the  U-shaped  support  in  the  rear  in  the  same 
manner.  The  brace  is  further  held  in  position  by  an  apron  covering  the 


Figure  2294.     Ridlon's  Convalescent  Brace. 


Figure  2295.     Hoadley's  Spine  Brace  for 
Pott's  Disease. 


lower  part  of  the  chest  and  abdomen  and  secured  to  the  uprights  by  lateral 
straps  and  buckles.  This  apron  should  extend  from  the  trochanter  major 
to  the  axilla  upon  each  side,  and  together  with  the  two  anterior  pads  pre- 


0   3  FJ  3  J 


POTT'S  DISEASE.  953 

viously  referred  to,  secures  all  .the  leverage  force  necessary,  leaving  the 
arms  and  axillae  free. 

Ridlon's  Spinal  Brace  for  Pott's  Disease,  as  illustrated  in  figure  2293,  is 
modified  from  one  of  the  earlier  forms  of  the  Taylor  brace.  The  parallel 
uprights  are  continuous  pieces,  and  the  pad-plates  are  screwed  to  them 
instead  of  forming  a  connecting  link  between  the  upper  and  lower  seg- 
ments. The  shoulder-pieces  are  adjustable.  There  are  two  cross-pieces, 
the  upper,  opposite  the  lower  borders  of  the  axillae  for  the  upper  straps  of 
the  apron,  and  the  under  at  the  lower  angles  of  the  scapulae  for  the 
shoulder  straps.  The  hip-band  passes  around  the  back  of  the  pelvis  from 
a  point  just  above  one  great  trochanter  to  the  same  point  on  the  opposite 
side. 

The  hip-band  and  shoulder-pieces  are  padded  with  blanketing  and 
covered  with  leather.  The  pads,  which  are  sewed  to  the  pad-plates,  are  of 
powdered  cork  or  piano  felt,  covered  with  canton  flannel.  The  brace  is 
secured  to  the  patient  by  an  apron  reaching  from  the  flexures  of  the  thighs 
to  the  level  of  the  axillae. 

The  brace  is  not  so  readily  fitted  over  a  severe  deformity  as  one  in  which 
the  parallel  uprights  are  in  three  parts,  as  indicated  in  the  description  of 
the  modern  Taylor  spinal  brace. 

Ridlon's  Convalescent  Brace,  as  traced  in  figure  2294,  differs  from  the 
one  last  described  only  in  omitting  the  cross-pieces  and  the  apron.  The 
shoulder-straps  pass  to  buckles  screwed  to  the  uprights  opposite  the  lower 
angles  of  the  scapulas.  The  brace  is  further  held  in  place  by  a  broad  belt 
passing  across  the  lower  abdomen. 

Hoadley's  Spinal  Brace  for  Pott's  Disease,  as  delineated  in  figure  2295, 
consists  of  two  parallel  uprights  secured  to  a  short  steel  cross-bar,  extending 
across  the  sacrum.  This  cross-bar  is  firmly  riveted  to  a  well-shaped  leather 
belt  encircling  the  pelvis  in  such  a  manner  as  to  rest  securely  on  the  iliac 
crests.  Large  thin  pads  are  provided  and  so  attached  to  the  uprights  that 
they  press  on  the  transverse  processes,  on  either  side  of  the  vertebral 
spines  and  over  the  diseased  vertebras.  The  uprights  diverge  near  their 
tops,  passing  to  each  side  of  the  neck  as  far  forward  as  the  apex  of  the 
shoulder  and  resting  just  below  the  roots  of  the  neck.  A  cross-bar  of  steel 
unites  the  uprights  at  the  point  of  divergence.  A  second  cross-piece  is 
attached  to  the  upright  bars  opposite  the  tenth  rib.  This  should  be  closely 
fitted  to  the  body,  and  long  enough  to  reach  on  either  side  to  the  posterior 
axillary  line.  The  ends  of  this  cross-piece  are  attached  by  straps  and 
buckles  to  the  upper  portion  of  the  uprights  at  the  shoulders.  These  straps 
in  most  cases  are  crossed,  the  chest  being  protected  at  the  point  of  pressure 
by  an  accurately  fitting  pad.  The  latter  should  present  a  crescent  shape 
with  a  convex  upper  margin  and  should  rest  on  the  sternum  just  below  the 
inner  clavicular  heads.  The  upper  outer  margins  should  rest  inside  the 
shoulder  sulci,  below  the  clavicles.  These  pads,  usually  about  2  inches 
wide,  should  be  accurately  fitted  to  each  patient.  They  should  be  thick 
and  well  rounded  at  their  upper  and  outer  margins,  thin  in  the  center  and 
at  the  under  margins.  The  uprights  should  be  attached  to  a  pelvic  band 
by  means  of  a  hinged  joint,  in  order  to  admit  of  perfect  adjustment,  no 
matter  in  what  position  the  patient  may  be  placed. 

Sayre's  Brace  for  Cervical  Spondylitis,  as  illustrated  by  figure  2296,  con- 
sists of  two  upright  bars  of  malleable  steel,  resting  upon  either  side  of  the 
spine,  the  upper  ends  diverging  over  the  shoulders,  upon  which  they  closely 
rest.  These  uprights  are  firmly  attached  to  a  steel  band  passing  half  around 


954 


ORTHOPEDIC    SURGERY. 


the  pelvis,  the  brace  being  held  in  place  by  shoulder  straps  and  an  abdom- 
inal apron  after  the  pattern  of  Taylor  described  by  figure  2292.  The 
uprights  and  sacral  band  are  properly  padded  at  all  points  where  they  come 
in  contact  with  the  skin.  Two  cross-bars  support  a  central  rod  with  uni- 


•iEEYN3ERS8.CD.Ny. 


Figure  2296.     Say  re's  Brace  for  Cervical  Pott's  Disease. 


versal  joints  to  which  a  head  support  is  attached.  Two  joints  are  of  the 
ball  and  socket  pattern,  and  may  be  held  in  any  desired  position  by  means 
of  set  screws.  The  upright  carrying  these  joints  may  be  elongated  by 
ratchet  and  key  after  the  manner  of  a  hip-brace.  The  head -piece  is  of 
malleable  steel  passing  from  the  base  of  the  skull  upward  and  forward  over 
each  ear,  encompassing  more  than  half  the  circumference  of  the  head.  It 
is  supplied  with  a  forehead-band  and  chin-piece  by  which  fixation  is 
secured. 


Figure  2297.     Goldthwaite's  Spinal  Brace  for  Pott's  Disease. 


Goldthwaite's  Spinal  Brace  for  Pott's  Disease,  as  depicted  in  figure  2297, 
is  a  modification  of  the  modern  Taylor  spinal  brace.  It  is  made  from 
annealed  steel  and  can  readily  be  bent  to  fit  a  varying  deformity.  Without 


POTT'S  DISEASE.  955 

the  chin  support,  the  brace  reaches  from  the  top  of  the  shoulders  to  the 
post-trochanteric  sulci,  and  thus  exerts  the  longest  possible  leverage. 
Riveted  to  the  surface  next  the  patient  is  a  piece  (or  two  pieces  as  shown 
in  the  illustration)  of  truss  leather.  Pads  may  be  added  at  the  site  of  the 
kyphosis  if  desired.  The  brace  is  held  in  place  by  an  apron  across  the 
chest  and  abdomen,  which  is  secured  with  straps  to  the  various  buckles. 
Perineal  straps  pass  from  the  lower  buckles  and  prevent  the  brace  from 
slipping  upward.  When  the  disease  is  above  the  eighth  dorsal  vertebra, 
the  chin-support  should  be  used.  This  plays  free  on  a  pivot  unless  the  dis- 
ease be  in  the  cervical  region  when  it  is  made  fast  by  a  set  screw.  The 
most  satisfactory  guide  for  making  the  brace  is  a  plaster  cast  of  the  patient's 
back,  made  while  lying  prone.  In  lieu  of  this,  an  outline  tracing  of  the 
line  of  the  spinous  processes  should  be  made  on  strong  wrapping  paper,  and 
the  curve  of  the  neck-piece  and  hip-piece  should  also  be  indicated. 

Jackets  for  Pott's  Disease. 

Jackets  or  corsets  consist  of  wide  firm  bands  or  belts  encircling  the  trunk 
usually  from  the  sterno-clavicular  articulation  to  the  great  trochanter,  or 
from  the  axilla  to  a  point  far  enough  below  the  iliac  crest  to  secure  good 
bearing  or  support.  When  constructed  without  a  jury  mast,  they  are  adapted 
only  for  cases  where  the  "disease  is  below  the  fifth  to  the  seventh  dorsal 
vertebra.  They  are  adjusted  to  fit  the  trunk  during  partial  suspension, 
when  the  spine  is  in  as  nearly  a  normal  position  as  possible.  They  act  not  as 
corrective  or  distractile  appliances,  but  simply  as  splints  to  retain  the  spine 
in  an  improved  position  secured  by  suspension. 

In  their  application  the  surgeon  should  seek  to  transfer  pressure  from 
diseased  to  healthy  tissues.  As  a  rule,  they  form  but  fairly  efficient  appli- 
ances, although  they  place  the  surgeon  independent  of  the  instrument 
maker.  They  possess  the  further  claimed  advantage  that  if  the  patient 
finds  them  uncomfortable  at  first,  they  can  not  be  changed  or  altered  without 
the  consent  and  assistance  of  the  surgeon.  They  are  objected  to  by  some 
operators  because  they  are  not  only  uncleanly,  but  after  being  worn  for 
some  time,  they  fit  loosely  as  a  rule,  and  thus  furnish  inadequate  support. 

Furthermore,  the  pressure  on  the  protruding  vertebra  changes  with  the 
size  of  the  abdomen  and  the  condition  of  the  latter  varies  with  each  meal. 
They  are  usually  constructed  from  plaster  of  paris  bandages,  silicate  of 
soda  bandages,  leather,  aluminum,  poroplastic  felt,  woven  wire,  wood,  etc., 
from  which  materials  they  may  remain  fixed  or  may  be  designed  in  corset 
form  that  they  may  be  removed  when  desired. 

Plaster  of  Paris  Jackets. 

These,  either  fixed  or  removable,  are  more  largely  employed  in  the 
treatment  of  Pott's  disease  than  any  other  form  of  appliance.  Their  great 
advantage  is  their  cheapness,  thus  permitting  their  employment  in  the 
treatment  of  poor  and  charity  patients.  They  may  be  applied  promptly 
and  in  sections  remote  from  an  instrument  maker,  saving  much  time  and 
expense. 

They  are  objectionable  because  the}7  are  clumsy,  often  heavy,  uncleanly, 
the  degree  of  pressure  can  not  be  changed  from  day  to  day,  they  do  not  absorb 
perspiration,  and  they  frequently  cause  excoriation  of  the  skin  by  chafing, 
which  occasionally  results  in  ulcers.  Unless  the  jackets  be  made  in  corset 
form,  this  may  occur  without  the  knowledge  of  the  surgeon,  as  the  affected 


956 


ORTHOPEDIC    SURGERY. 


parts  can  not  be  inspected.  They  are  almost  unbearable  in  some  cases, 
owing  to  their  irritating  effect  on  the  skin.  Like  braces,  they  are  often 
improperly  applied,  demonstrating  that  it  is  skill  and  knowledge  and  not 
means  that  secure  proper  treatment. 

When  fixed  jackets  are  employed,  a  reasonable  degree  of  cleanliness 
may  be  maintained  by  passing  a  long,  fine  soft  towel  between  the  skin  and 
the  jacket  from  sternum  to  pubes.  This  may  be  accomplished  with  a  thin 
wooden  bar  or  a  rod  of  flexible  material.  After  being  passed  by  holding 
the  ends,  one  in  each  hand,  the  towel  may  be  passed  back  and  forth,  with 
a  sawing  motion,  and  this  continued  until  the  trunk  has  been  encircled  in 
the  rubbing  process.  A  "change  of  shirt"  may  be  secured  by  placing  two 
on  the  patient,  the  inner  without  arms,  with  open  shoulder  straps,  and  not 
included  in  the  jacket  mass.  This  may  be  replaced  by  sewing  the  top  of 
the  clean  one  to  the  bottom  of  the  first  and  then  pulling  the  latter  up  over 
the  head  and  drawing  the  second  one  into  place.  As  they  readily  absorb 
urine,  they  may  be  varnished  in  case  of  small  children,  thus  preventing  this 
unpleasant  complication. 

In  the  application  of  a  jacket  it  is  necessary  to  secure  suspension.  This 
may  be  best  obtained  by  employing  the  apparatus  known  as  Sayre's.  Its 
use  gives  the  operator  full  control  of  the  patient  and  enables  him  to  work 
with  ease  and  rapidity.  If  the  patient  be  a  child  or  below  medium  height, 
he  may  be  allowed  to  stand  on  a  box,  stool  or  other  similar  article,  thus 
enabling  the  operator  to  place  the  trunk  of  the  patient  at  a  height  where 
manipulation  is  easy. 


Figure  2298.     Sayre's  Suspension  Apparatus. 


Figure  2299.     Removable  Plaster  Jacket. 


Sayre's  Suspension  Apparatus,  as  shown  in  figure  2298,  consists  of  a 
curved  iron  cross-bar,  provided  with  four  indentations  or  points  of  bearing 
to  which  are  attached  an  adjustable  head  and  chin  collar  with  straps  and 
axillary  supports.  By  a  ring  in  the  center  of  the  bar,  it  is  attached  to  a 
movable  pulley  by  which  it  may  be  connected  by  a  hook  securely  fastened 
to  the  ceiling  where,  with  a  proper  cord,  a  patient  may  be  suspended. 
Generally  they  are  manufactured  in  three  sizes,  large,  medium  and  small. 

If  required  for  gymnastic  purposes  and  an  accurate  and  closely-fitting 


POTT'S  DISEASE.  957 

collar  is  desired,  the  surgeon  in  ordering  should  give  the  following  measure- 
ments: Weight,  height  and  circumference  of  head  around  the  chin  and  back 
of  neck.  In  taking  the  latter  measurement,  care  should  be  exercised  to  see 
that  the  tape  encircles  these  parts  in  an  even  horizontal  line. 

In  the  absence  of  a  suspension  apparatus,  or  if  the  patient  can  not  endure 
the  strain  incident  to  such  a  proceeding,  the  surgeon  may  employ  a  thin 
cloth  hammock,  folding  the  latter  smoothly  about  the  trunk  while  the 
patient  is  resting  face  downward  and  including  the  hammock  in  each  turn 
of  the  bandage.  After  the  jacket  has  hardened,  the  projecting  ends  of  the 
hammock  may  be  cut  away. 

Bandages  should  be  selected  from  3  to  5  inches  in  width,  and  if  kept 
on  hand,  they  should  be  hermetically  sealed  or  stored  in  air-tight  jars.  When 
required  for  use,  they  should  be  placed  on  end  in  a  basin  or  pail  containing 
enough  water  to  completely  immerse  them.  As  soon  as  they  are  deposited  in 
the  water,  bubbles  of  air  will  be  seen  to  rise  to  the  surface,  freely  for  a  time. 
When  this  action  ceases,  the  surgeon  may  know  that  after  being  squeezed 
nearly  dry,  the  bandage  is  ready  for  use.  Additional  stability  may  be 
secured  by  rubbing  a  limited  quantity  of  dry  plaster  between  each  layer  of 
the  cloth  after  its  application. 

Hooks  or  eyes  of  special  construction  may  be  embedded  in  plaster 
jackets  and  used  for  the  attachment  of  extension  and  traction  mechanism. 


Figure  2300.     Schreiber's  Plaster  Figure  2301.     Plain  Lacing  Hook. 

Jacket  Eye. 

Schreiber's  Plaster  Jacket  Eye,  the  form  of  which  is  made  clear  in  figure 
2300,  is  a  metal  eye  attached  to  a  perforated  tin  base.  They  may  be  in- 
cluded in  the  jacket  mass,  the  eyes  being  allowed  to  protrude  through  slits 
cut  in  the  bandage  that  includes  them.  r 

The  Plain  Lacing  Hooks,  as  illustrated  by  figure  2301,  are  of  a  pattern 
manufactured  particularly  for  such  lacings  as  are  subject  to  considerable 
strain.  They  are  especially  adapted  for  surgical  work.  By  means  of  rivets 
they  may  be  securely  attached  to  a  plaster  jacket,  supplying  means  by  which 
perfect  adjustment  may  be  secured. 

Plaster  jackets  may  be  opened  vertically  and  converted  into  corsets  by 
providing  them  with  lacing  hooks  that  they  may  be  removed  and  re- 
applied  as  desired.  The  opening  may  be  in  front  or  at  the  side  directly 
under  the  axilla.  It  is  claimed  that  the  latter  method  does  not  strain  the 
jacket  on  removal  and  re-application  as  severely  as  the  ordinary  plan  where 
an  opening  is  made  through  the  center. 

A  jacket  should  be  cut  and  removed  before  it  is  thoroughly  dry,  after 
which  it  may  be  hardened  in  a  heating  room,  over  a  kitchen  stove,  in  an 
oven,  or  some  similar  place  where  heat  can  be  obtained.  In  all  such  cases 
the  jacket,  after  removal,  should  be  encircled  with  roller  bandages  that  it 
may  not  warp  or  lose  its  proper  shape  during  the  hardening  process.  Such 
jackets  should  be  reapplied  only  while  the  patient  is  suspended. 

As  the  appliances  necessary  for  cutting  plaster  jackets  are  shown  by 
figures  2230  to  2239,  no  further  description  is  here  necessary. 


958  ORTHOPEDIC    SURGERY. 

Shirts. 

Care  should  be  exercised  in  choosing  the  undershirt  to  be  worn  by  the 
patient  and  incorporated  in  the  jacket.  It  should  be  sleeveless  and  without 
seams,  and  should  fit  closely  to  the  body.  Sayre  recommends  one  of  suffi- 
cient length  to  extend  to  the  knees,  that  after  the  completion  of  the  jacket  it 
may  be  turned  upward,  drawn  over  the  latter  and  stitched  to  the  upper 
margin,  thus  forming  a  soft  internal  and  external  covering.  If  the  jacket 
is  to  be  opened  and  converted  into  a  corset,  the  undershirt  is  not  turned 
until  after  the  jacket  has  been  removed.  If  such  a  shirt  can  not  be  procured, 
stockinet  in  different  sizes  may  be  used  instead. 

The  method  of  applying  a  jacket  is  not  considered  to  be  within  the  prov- 
ince of  this  work.  For  such  information  we  refer  the  reader  to  the  stan- 
dard text-books  in  almost  all  of  which  explicit  directions  are  given. 

The  Removable  Plaster  Jacket,  seen  in  figure  2299,  illustrates  what  may 
be  accomplished  with  plaster  jackets  after  removal.  They  may,  if  desired, 
be  lined  and  the  edges  trimmed  with  cloth,  chamois  or  other  soft  material. 
The  cut  margins  may  be  faced  with  leather  or  strong  canvas,  through  which 
shoe  or  lacing  hooks  may  be  riveted,  thus  forming  a  convenient  appliance 
of  neat  appearance. 

Various  other  modifications  of  removable  plaster  jackets  have  been  de- 
vised and  used  from  time  to  time.  Roberts'  pattern  consists  of  two  seg- 
ments jointed  and  arranged  with  a  spiral  spring,  compressed  in  such  a  man- 
ner as  to  produce  continuous  extension.  Wyeth  designed  one  in  which 
similar  extension  was  secured  by  rack  and  pinion.  These  and  others  of 
similar  nature  have,  however,  failed  to  take  the  place  of  the  plain  jacket 
and  it  still  remains,  particularly  among  the  poor,  the  mainstay  in  treating 
antero-posterior  curvatures. 

Silicate  of  Soda  Jackets. 

As  silicate  of  soda  bandages  have  been  described  on  page  922,  they 
do  not  require  further  mention  in  this  chapter.  They  possess  the  advan- 
tages of  being  more  durable  and  much  lighter  than  plaster  of  paris  and  of 
being  more  easily  perforated,  because  with  a  mallet  or  hammer  and  an 
ordinary  gun-wad  cutter,  openings  may  be  made  through  them  as  required. 
They  require,  however,  a  longer  time  to  harden. 

Leather  Jackets. 

Leather  is  largely  employed*  as  a  substitute  for  plaster  of  paris,  not  only 
because  it  is  easily  worked  and  durable,  but  because  it  can  be  kept  reason- 
ably clean.  While  appliances  from  this  material  are  usually  called  sole-leather 
jackets,  they  are  seldom  if  ever  constructed  from  this  material,  ordinary 
saddler's  skirting  being  used  instead. 

The  Leather  Jacket,  displayed  by  figure  2302,  is  of  the  regular  form  as  gen- 
erally fitted  to  patients.  This  leather,  after  being  cut  into  pieces  of  the  re- 
quired shape  and  size  and  soaked  in  warm  water  for  several  hours,  may  be 
applied  without  stitching  directly  to  the  body  of  the  patient.  After  being 
carefully  laid  in  place,  each  piece  being  molded  accurately  to  the  body, 
they  may  be  firmly  secured  by  encircling  the  whole  with  roller  bandages 
to  be  kept  in  place  until  the  leather  is  thoroughly  dry.  This  usually  re- 
quires about  twelve  hours.  After  the  leather  has  hardened,  the  ban- 
dages and  leather  pieces  may  be  removed,  the  edges  of  the  latter  trimmed 
and  sewed  together  and  the  jacket  completed.  Care  should  be  taken  to  see 
that  the  points  of  union  are  free  from  ridges  and  uneven  surfaces. 


POTT  S    DISEASE. 


959 


If  the  surgeon  does  not  desire  to  undertake  the  construction  of  such  a 
jacket,  he  may  make  a  mold  of  the  body  of  the  patient,  following  the  same 
plan  as  when  applying  a  plaster  of  paris  jacket  during  suspension.  This 
mold  may  be  sent  to  the  instrument  maker,  a  cast  made  in  plaster,  and 
over  the  latter  he  may  form  a  perfect-fitting  jacket.  In  such  cases  the 
leather  may  be  forced  into  the  required  shape  by  winding  a  rope  around 
the  cast,  the  successive  strands  lying  against  each  other,  the  whole  being 


Figure  2302.     Leather  Jacket  with  Stays  for  Strengthening. 


hammered  until  pressed  into  shape.  When  partially  dry,  the  rope  may  be 
removed,  the  jacket  perforated  with  a  hammer  and  gun-wad  cutter  without 
removing  it  from  the  cast,  and  the  whole  then  placed  in  the  sun  or  a  warm 
room  to  harden.  Many  patients  require  that  the  leather  be  reenforced  with 
steel  stays  much  after  the  manner  of  ordinary  corsets.  In  cases  of  adults 
where,  owing  to  neglect  or  improper  treatment,  much  deformity  exists,  the 
leather  jacket  forms  an  ideal  appliance.  It  is  durable  and  affords  a  good 
support. 

Phelps'  Aluminum  Jacket  is  portrayed  in  figure  2303.  The  use  of  this 
material  furnishes  the  lightest,  neatest  and  most  durable  jacket  in  the 
market.  As  it  is  thin,  it  does  not  interfere  with  the  clothing ;  in  fact,  this 
appliance  may  be  worn  without  exhibiting  any  evidence  of  its  existence. 
Furthermore,  it  may  be  worn  during  bathing,  thus  proving  a  great  benefit 
to  patients  who  are  not  permitted  to  place  themselves  in  a  sitting  or  stand- 
ing posture  without  the  use  of  a  brace. 

As  usually  constructed,  they  weigh  from  i  to  2  pounds.  They  may  be 
perforated  with  large  openings,  so  that  they  will  be  cool  and  comfortable. 
To  avoid  oxidation,  they  may  be  covered  with  water-proof  enamel,  thus 
rendering  them  quite  durable. 

They  are  manufactured  by  swaging  two  sheets  of  aluminum  over  an 
iron  mold.  This  mold  must  be  made  from  a  plaster  cast  obtained  in  the 
usual  way.  When  properly  fitted,  the  two  sheets  or  halves  are  hinged  at 


960 


ORTHOPEDIC    SURGERY. 


the  back  and  supplied  in  front  with  automatic  clasps.  Owing  to  the  ex- 
pense, but  a  limited  number  are  in  use  at  this  time.  As  their  advantages 
become  better  known,  however,  it  is  thought  a  much  larger  demand  will  be 
created  for  them. 


Figure  2303.    Phelps'  Aluminum  Jacket.  Figure  2304.    Andrews'  Cloth  Jacket. 

Andrews'  Brace  for  Pott's  Disease,  as  exhibited  in  figure  2304,  com- 
bines the  correcting  influence  of  the  splint  with  the  passive  action  and  com- 
fort afforded  by  the  corset.  The  first  tends  to  relieve  the  inflammation  by 
pressing  upon  the  articular  processes  from  behind,  thus  in  a  measure  reliev- 
ing the  bodies  of  the  vertebrae  of  weight  and  permitting  them  to  recover 
spontaneously.  The  latter  acts  as  an  inverted  cone,  for  when  tightly  laced, 
it  tends  to  push  upward  from  the  hip,  thus  producing  as  light  traction, 
besides  furnishing  a  firm  support  for  the  chest. 

Felt. 

Poroplastic  felt  consists  of  a  soft,  loose,  mixed  fiber,  formed  in  sheets 
and  saturated  with  shellac,  resin  or  similar  substances.  The  hard- 
ening material  employed  must  be  one  that  may  be  softened  by  heat  but 
which  when  cold,  possesses  the  necessary  firmness  for  the  use  for  which  it  is 
intended.  The  advantages  claimed  for  this  material  are  its  lightness,  thus 
being  less  burdensome  to  the  patient;  high  porosity,  thus  permitting  the 
escape  of  perspiration;  durability,  for  under  ordinary  circumstances  a  jacket 
will  last  from  12  to  18  months,  and  the  lesser  advantage  that  the  material 
becomes  hard  in  from  5  to  10  minutes  after  being  applied.  Its  disadvan- 
tages lie  in  the  fact  that  it  requires  greater  skill  in  handling  and  is  much  more 
expensive,  although  the  latter  item  is  partially  offset  by  the  fact  that  a 
jacket  may  be  remolded  as  often  as  desired. 

Suspension  in  Pott's  disease,  when  intelligently  directed,  forms  one  of 
the  most  effectual  methods  of  treatment.  The  result  of  this  principle,  when 
properly  applied,  obliterates  all  unnatural  curves  so  far  as  existing  con- 
ditions will  admit.  The  degree  of  suspension  must  vary  with  the  nature 
of  the  case  and  the  apparatus  employed.  It  may  be  complete  or  partial. 

Complete  Suspension  is  used  only  as  a  temporary  expedient,  either  for 
securing  a  better  position  of  the  parts  while  constructing  or  applying 


POTT'S  DISEASE. 


961 


jackets,  braces,  etc.,  or  for  diagnostic  or  gymnastic  purposes.  This  may 
be  secured  by  the  apparatus  shown  by  figure  2298,  or  if  perf erred,  one  in 
portable  form  may  be  employed. 

Sayre's  Suspension  Apparatus  with  Tripod,  as  described  by  figure  2305, 
is  sometimes  employed  instead  of  the  ceiling  attachment  shown  by  figure 
2298,  because  it  may  be  transported  and  placed  in  position  wherever  desired. 


Figure  2305.     Sayre's  Suspension  Apparatus 
with  Tripod. 


Figure  2306.    Darrach's  Wheel  Crutch. 


It  is  particularly  adapted  as  a  means  for  securing  gymnastic  exercises,  and 
for  this  purpose,  the  rope  should  be  arranged  with  a  number  of  small  egg- 
shaped  blocks,  which  the  patient  easily  and  firmly  grasps.  When  once  prop- 
erly adjusted,  the  patient  may  take  daily  exercise,  securing  any  degree  of  sus- 
pension desired.  They  are  usually  so  constructed  that  the  treatment  may  be 
carried  on  without  assistance  from  other  parties,  the  patients  raising, 
suspending  and  lowering  themselves. 

Darrach's  Wheel  Crutch,  as  explained  by  figure  2306,  unless  supplied 
with  a  head-support,  is  applicable  only  to  deformities  in  the  lower  dorsal 
and  lumbar  regions;  it  has  also  been  advised  for  certain  cases  of  paralysis 
of  the  lower  extremities.  It  consists  of  a  supporting  frame  constructed 
from  gas  pipe  resting  upon  four  small  rubber-tired  wheels,  arranged  with  a 
view  of  giving  to  patients  a  certain  amount  of  freedom  and  out-of-door 
exercise.  Our  experience,  except  in  a  few  cases,  leads  us  to  conclude  that 
the  apparatus  is  of  doubtful  utility  because  if  it  is  strong  enough  to  support 
the  weight  of  the  patient,  it  will  be  found  too  heavy  and  cumbersome  for 

61 


962 


ORTHOPEDIC    SURGERY. 


use.  This,  together  with  the  fact  that  it  can  be  used  only  upon  level  floors 
and  walks,  renders  it  impracticable  in  most  cases. 

Partial  Continuous  Suspension,  except  during-  recumbency,  may  be  secured 
by  combining  a  suspension  apparatus  with  either  a  brace  or  jacket.  It  is 
applicable  only  where  the  affection  involves  the  upper  dorsal  or  cervical 
region.  Such  applia.nces  are  usually  called  jury  masts.  While  nearly  all 
forms  are  objected  to  because  of  their  unsightly  appearance,  they  are  a 
necessity  in  the  treatment  of  this  class  of  cases. 

They  consist  of  mechanism  for  supporting  the  head  either  by  a  system  of 
flexible  straps  or  slings  attached  to  an  over-bar,  or  by  resting  the  chin  and 
occiput  in  rings  or  troughs  supported  by  upright  shafts.  If  the  latter  are 
employed,  they  may  be  attached  by  pivots  to  posterior  braces. 

Jury  Masts. 

Jury  masts  usually  consist  of  a  steel  shaft  or  upright,  fitting  the  contour 
of  the  neck  and  head,  the  base  of  which  is  firmly  attached,  usually  with  an 
adjustable  arrangement,  either  to  a  brace  or  jacket. 

The  modern  orthopedic  surgeon  seems  to  have  entirely  abandoned  the 
old-style  over-bar  jury  mast,  preferring  in  cases  of  upper  dorsal  and  cer- 
vical cases  the  chin-pieces  of  Taylor,  Whiteman,  Sherman  and  others. 


Figure  2307.    Sayre's  Jury  Mast. 


Figure  2308.     Showing  Sayre's  Jury  Mast 
Applied  to  Leather  Spinal  Jacket. 


Sayre's  Jury  Mast,  as  indicated  in  figure  2307,  consists  of  an  upright 
shaft  as  above  described.  A  cross-bar  is  attached  to  this  at  a  point  where 
it  rests  directly  over  the  head.  The  joint  is  swiveled,  and  from  this  bar 
depend  the  straps  that  sustain  the  weight  of  the  head.  The  surgeon  should 
see  that  the  cross-bar  is  adjusted  to  rest  on  top  of  the  shaft-ending  and 
exactly  over  the  vertex  of  the  head,  otherwise  the  direction  of  traction 
may  be  posterior  or  anterior  to  the  line  desired.  Direct  contact  is  effected 
by  means  of  a  collar  or  chin-piece  encircling  the  base  of  the  head  and  to 


POTT'S  DISEASE. 


9G3 


\yhich  the  straps  above  referred  to  are  attached.  This  apparatus  is  objec- 
tionable because  it  does  not  furnish  a  firm  support;  the  degree  of  traction 
may  be  easily  changed  by  the  patient  if  for  an}*  reason  found  uncomfort- 
able, and  it  presents  a  most  unsightly  appearance.  For  the  latter  reason 
alone  they  are  often  laid  aside  by  parents  and  patients  long  before  their  use 
should  be  discontinued. 


Figure  2309.     Sherman's  Suspension  Apparatus. 

Sherman's  Suspension  Apparatus,  as  illustrated  in  figure  2309,  consists 
of  a  square  base  with  flexible  metallic  strips  similar  to  the  pattern  of  Sayre. 
The  center  of  the  metallic  frame  is  supplied  with  a  bar  arranged  to  slide 
perpendicularly,  fixation  at  any  given  point  being  secured  by  a  set  screw. 
This  bar  is  supplied  with  a  slotted  post,  the  opening  in  which  is  provided 
with  a  shaft  or  pin.  The  latter  is  used  for  attaching  and  carrying  a  bifur- 
cated upright  that  forms  the  basis  of  support.  This  bar  is  in  wishbone-form 
and  curved  forward  so  as  to  contact  the  chin-piece  directly  under  each  ear. 
The  chin-piece  consists  of  a  flaring  bow  preferably  of  aluminum  and  swaged 
so  as  to  fit  closely  around  the  inferior  maxilla.  The  anterior  portion  of  this 
is  not  padded,  the  leather  cover  including  only  that  portion  that  encircles  the 
head  posterior  to  its  attachment  with  the  upright.  A  strap  at  the  base  of 
the  head  keeps  the  ends  of  the  bow  in  proper  adjustment.  The  chin-piece 
is  attached  to  the  curved  uprights  by  a  French  lock,  the  eye  of  the  latter  so 
adjusted  that  the  surgeon  may  readily  determine  whether  or  not  the  proper 
degree  of  suspension  is  secured.  The  latter  may  be  increased  or  decreased 
by  the  upright  bar  first  described.  Mechanically  it  would  seem  that  this 
brace  supplies  a  strong  and  stable  support  with  the  least  possible  weight  of 
material.  It  is  more  sightly  in  appearance  than  the  various  forms  of 
supra-cranial  apparatus.  It  furnishes  a  perfect  poise  and  prevents  rotation 


964 


ORTHOPEDIC  SURGERY. 


of  the  spine.  The  brace  may  be  easily  applied  by  first  suspending  two 
strings  from  the  ceiling,  gas  fixture,  cross-bar  or  suspension  apparatus, 
placing  the  brace  in  position  on  the  patient  and  tying  the  strings  together 
under  the  post  that  supports  the  upright.  The  post  and  bar  may  then  be 
removed  and  the  brace-supporting  frame  incorporated  in  the  plaster  mass. 
After  the  first  few  layers  of  plaster  bandage  have  been  applied,  the  upright 
bar  and  post  may  be  again  suspended  in  the  string,  thus  securing  the  same 
position  that  was  occupied  by  the  brace  before  the  plaster  was  applied. 
With  proper  care  this  will  ensure  a  perfect  adjustment. 


Figure  2310.    Leather  Jacket  with  Sayre's 
Jury  Mast  Attached. 


Figure  2311.     Roberts'  Jury  Mast. 


The  Leather  Jacket  with  Sayre's  Jury  Mast,  illustrated  in  figure  2310, 
is  introduced  to  show  how  this  pattern  of  head-support  may  be  attached  to 
jackets  and  corsets  of  various  forms.  The  cross-bars  and  flexible  metallic 
strips  shown  in  figure  2298,  may  be  firmly  riveted  to  almost  any  form  of 
jacket.  If  provided  with  several  strips  of  large  size,  a  sufficient  contact 
surface  may  be  secured  to  furnish  all  necessary  support. 

Roberts'  Jury  Mast,  as  exhibited  in  figure  2311,  differs  from  the  pattern 
of  Sayre  in  that  the  brace-support  is  bifurcated,  and  the  two  arms  curved 
forward  and  inward  under  the  axillae,  as  clearly  shown  in  the  illustration. 
The  object  of  this  form  of  truncal  shaft  is  to  secure  a  state  of  stable  equilib- 
rium by  bringing  the  center  of  gravity  of  the  whole  within  the  area  of  the 
base.  As  in  this  instrument,  the  center  of  gravity  is  inferior  to  the  lowest 
point  of  the  shaft,  the  weight  of  the  head  and  neck  is  supported  without 
undue  pressure  on  that  portion  of  the  brace  brought  in  contact  with  the 
affected  vertebra?. 

Taylor's  Circular  Support  for  the  Head,  as  set  forth  in  figure  2312,  con- 
sists of  an  ovoid  ring  passing  around  the  neck  and  arranged  with  a  hinged 
joint  by  which  it  may  be  opened.  This  metallic  collar  is  pivoted  to  the  back 


POTT  S    DISEASE. 


965 


Figure  2312.    Taylor's  Circular  Support  for  Head. 

brace  supports,  the  connection  being  such  that  the  collar  may  be  raised  or 
lowered  as  desired.  While  this  requires  greater  skill  and  care  in  adjust- 
ment, it  obtains  better  fixation  and  is  more  satisfactory  than  a  jury  mast. 


Figure  2313.    Goldthwaite's  Modification  of  Taylor's  Brace. 


ORTHOPEDIC    SURGERY. 


Furthermore,  with  a  little  care  in  the  arrangement  of  garments,  the  appa- 
ratus may  be  wholly  concealed,  thus  overcoming  one  of  the  chief  objections 
to  the  old-fashioned  jury  mast. 

Goldthwaite's  Modification  of  the  Taylor  Brace,  as  it  appears  in  figure 
2313,  is  constructed  by  extending  the  two  back-bars  until  they  include  the 
head  in  a  gentle  curve  as  shown  in  the  illustration.  The  head  is  secured 
and  fixed  by  lateral  bands  strengthened  and  held  in  place  by  a  third  band, 
which  extends  in  a  vertical  direction,  passing  under  the  chin. 


Figure  2314.    Plain  Leather  Collar. 


Figure  2315.    Burrell's  Metal  Collar. 


The  Plain  Leather  Collar,  as  manifest  in  figure  2314,  is  sometimes  em- 
ployed instead  of  a  jury  mast.  Thomas  advised  that  one  be  constructed 
from  a  piece  of  stout  webbing  fitting  loosely  about  the  neck,  the  ends 
being  stitched  together.  This  may  be  wound  with  sheet  wadding  or  oakum 
until  of  the  required  size,  when  it  is  covered  by  winding  with  roller  band- 
ages. As  this  is  compressed  or  matted  by  use  each  day,  new  material  is 
added  until  a  size  and  form  for  permanent  use  is  secured.  It  is  then  re- 
moved, sent  to  an  instrument  or  harness  maker  and  covered  with  leather. 
As  shown  in  figure  2314,  they  must  necessarily  be  supplied  with  a  joint, 
secured  by  lacings  or  buckles  that  they  may  be  removed  and  re-applied.  Its 
advantages  claimed  are  its  low  price,  the  comfort  with  which  it  may  be 
worn  and  its  more  satisfactory  appearance  when  compared  with  a  jury  mast. 
It  is  beneficial  only  in  cervical  cases. 

Burrell's  Metal  Collars  may  be  made  by  securing  firm,  closely  woven 
brass  wire  gauze,  fitting  it  in  pieces  to  the  neck  and  sending  them 
with  proper  instructions  to  the  instrument  maker.  The  general  design  is 
represented  in  figure  2315. 

This  plan  is  preferable  to  the  leather  collar  because  it  avoids  the  large 
thick  roll  of  the  former;  it  is  more  firm,  and  when  desired,  it  can  be 
attached  by  a  pivot  to  a  back-brace. 

Recumbency  may  be  secured  by  placing  the  patient  on  a  bed  or  similar 
appliance  and  confining  his  movements  so  as  to  afford  absolute  rest  to  the 
spine.  The  bed  must  be  one  that  will  remain  flat  or  nearly  so  under  his 
weight,  because  any  sagging  of  the  support  increases  the  spinal  curvature. 


POTT  S   DISEASE. 


967 


It  may  be  advantageously  employed  in  acute  stages,  particularly  if  inflam- 
mation in  a  pronounced  degree  is  present.  .  Its  disadvantages  are  many, 
among  which  are  want  of  exercise,  and  enfeebling  of  the  general  system, 
resulting  in  a  loss  of  reparative  power. 

Special  appliances  called  traction  beds  or  frames  have  been  devised,  some 
of  which  are  in  reality  but  plain  stretcher  frames  used  not  only  as  a  means 
of  securing  a  level  surface  upon  which  to  place  the  patient,  but  as  a  means 
of  conveying  him  about.  As  no  braces  or  other  appliances  are  necessary, 
the  method  is  within  reach  of  all. 


Figure  2316.    Bradford's  Stretcher  Bed. 


Bradford's  Stretcher  Bed,  as  shown  in  figure  2316,  is  extensively  em- 
ployed when  recumbency  is  indicated,  as  in  Pott's  disease  and  diseases 
of  the  hip-  and  sacro-iliac -joint.  It  consists  of  an  oblong  iron  frame,  usually 
of  gas-pipe,  over  which  are  stretched  two  pieces  of  canvas  so  adjusted  that 
they  may  be  removed  for  cleansing.  The  frame  should  be  from  2  to  4 
inches  wider  and  from  6  to  10  inches  longer  than  the  patient.  The  two 
pieces  of  canvas  in  their  united  length  should  be  about  10  inches  shorter 
than  the  frame,  thus  allowing  an  open  central  space  of  sufficient  width  to 
permit  the  use  of  a  bedpan  when  the  patient  is  lifted  on  the  bed  from  the 
mattress  beneath. 

Recumbency  in  children  may  be  assured  by  passing  a  strap  around  each 
shoulder  and  pinning  or  otherwise  securing  them  to  the  canvas.  The  pel- 
vis or  a  limb  may  be  immobilized  in  the  same  manner,  or  a  broad  band  of 
muslin  or  a  towel  may  be  passed  around  both  patient  and  frame  and  secured. 

Traction  may  be  obtained  in  hip-disease  by  weight  and  pulley,  by  an 
elastic  strap  and  flange  at  the  foot  of  the  frame  or  by  a  traction  splint. 
Counter-traction  may  be  obtained  by  means  of  a  perineal  strap  attached  to 
a  curved  flange,  secured  to  the  side  bar  of  the  frame.  Traction  of  the  head 
may  be  accomplished  by  weight  and  pulley  or  by  an  elastic  strap. 


Figure  2317.     Selva's-Bradford's  Recumbent  Frame. 

Where  necessary  to  assist  in  traction,  one  end  of  the  bed  may  be 
elevated  to  any  desired  angle.  No  special  bedding  is  necessary  in  the  use 
of  this  appliance,  and  canvas,  sheets,  etc.,  maybe  changed  when  desired. 
Resting  on  the  stretcher  bed,  the  patient  can  be  moved  without  discomfort 
and  without  disturbing  the  diseased  parts,  and  may  be  carried  from  one 
room  to  another  or  treated  to  an  airing  out-of-doors.  In  this  line  of  appa- 
ratus many  expensive  and  complicated  devices  have  been  constructed.  They 
embrace  complicated  beds,  many  of  which  are  arranged  with  cranks,  pulleys 
and  elaborate  mechanism.  Scarcely  one  of  these  beds  possesses  the  advan- 
tages of  the  plain  iron  frame  above  described.  Its  more  general  use  would, 
we  believe,  prove  a  boon  alike  to  patients,  nurses  and  physicians. 


ORTHOPEDIC    SURGERY. 


Selva's-Bradford's  Recumbent  Frame,  as  shown  by  figure  2317,  differs 
from  the  pattern  of  Bradford  only  in  that  the  lateral  bars  are  curved  up- 
ward in  bridge-form  at  a  point  opposite  the  resting-place  of  the  curvature 
in  the  patient  to  be  treated.  The  amount  of  elevation  is  usually  3  to  5 
inches,  thus  placing  the  seat  of  deformity  on  a  higher  level  than  the  head 
and  limbs,  and  securing  a  counter-curvature.  At  the  point  of  elevation  the 
canvas  is  attached  to  the  bars  by  means  of  side-straps  or  laces,  so  that  the 
amount  of  elevation  or  over-curvature  may  be  changed  if  desired.  Pads 
are  provided  to  rest  on  each  side  of  the  spine,  thus  avoiding  pressure  on  the 
prominent  portions  of  the  vertebrae. 

Recumbent  Litters. 

Wheel  litters  enable  patients  not  only  to  be  moved  about  from  room 
to  room  but  to  be  taken  out-of-doors,  thereby  enjoying  the  benefits  of  fresh 
air,  sunlight,  change  of  scene,  etc. 


Figure  2318.    Schapps'  Wheel  Litter. 

Schapps'  Wheel  Litter  for  cases  of  spinal  curvature,  as  depicted  in 
figure  2318,  consists  of  an  iron  stretcher  formed  by  lacing  a  heavy  canvas  on 
an  iron  frame,  and  mounting  the  whole  on  rubber-tired  suspension  wheels. 
One  end  of  the  bed  frame  is  so  adjusted  that  it  may  be  placed  at  any  height, 
thus  securing  an  oblique  position  that  may  be  used  in  obtaining  traction,  the 
head  or  upper  end  being  provided  with  a  pulley  for  this  purpose.  The  can- 
vas is  provided  with  a  narrow  oval  opening  for  purpose  of  defecation  and 
urination.  In  a  cot  4  feet  in  length,  this  opening  is  usually  about  2^/2,  by  6 
inches,  with  its  center  about  three-fifths  of  the  distance  from  the  head  end 


Figure  2319.     Schapps'  Litter  Frame.     Figure  2320.     Schapps'  Litter 

Frame  with  Canopy  Top. 


Figure  2321.     Schapps'  Litter 
Frame  in  Bed  Form. 


of  the  canvas.  For  adults,  the  opening  should  be  somewhat  nearer  the 
head,  but  should  be  .fitted  to  the  patient.  This  opening  may  be  covered 
with  a  flap  when  not  in  use.  The  patient  may  be  permanently  secured  in 


POTT  S    DISEASE. 


969 


proper  position  by  means  of  shoulder  straps,  leg  straps,  pelvic  belt,  etc. , 
all  of  which  should  be  so  arranged  that  they  may  be  released  when  required. 
To  ensure  comfort,  a  pillow  may  be  placed  under  the  thighs  and  loins  be- 
fore the  straps  are  adjusted.  Pads  should  be  provided  to  rest  laterally 
along  the  back,  thus  relieving  the  spinous  processes  of  the  vertebrae  from 
pressure.  In  cases  of  cervical  deformity,  a  pad  should  be  placed  under  the 
neck  to  assist  in  correcting  the  deformity  by  pressure  on  the  superincumbent 
parts.  These  pads  should  be  made  from  boiler  felt.  All  padding  should 
be  fastened  permanently  to  the  canvas,  which  should  be  covered  with  a 
folded  sheet,  extending  from  the  head  nearly  to  the  end  of  the  opening.  A 
second  sheet,  also  folded,  should  fill  the  balance  of  the  uncovered  space. 
In  cases  of  dorsal  and  lumbar  curvature,  straps  are  placed  across  the  patient, 
one  resting  upon  each  side  of  the  deformity  to  increase  the  leverage  caused 
by  the  weight  of  the  patient.  The  amount  of  this  pressure  may  be  regu- 
lated at  will.  Traction  may  be  secured  by  the  head-sling  and  weight  over 
a  pulley,  or  the  head-sling  may  be  attached  to  the  frame  and  the  stretcher 
placed  obliquely  to  secure  counter-pressure. 

Schapps'  Stretcher  Frame,  as  illustrated  in  figures  2319  to  2321,  shows 
three  forms  in  which  the  stretcher  frame  may  be  constructed.  The  first 
exhibits  an  appliance  similar  to  the  one  before  described  but  heavier. 


A  B  C 

Figure  2322.     Methods  of  Securing  Traction  during  Recumbency.    (Schapps.) 

This  is  particularly  adapted  for  use  out-of-doors.     Figure  2320  illustrates  a 
heavy  frame  with  canopy  designed  for  adult  use.     Figure  2321  portrays 


Figure  2323.     Schapps'  Garment  for  Patients  with  Spinal  Curvature. 


the  same  frame  in  cot  form.  Its  advantages  are  many.  It  not  only  may  be 
procured  at  a  low  price,  but  furnishes  a  cool  and  comfortable  bed  for 
patients  afflicted  with  almost  any  form  of  disease. 


ORTHOPEDIC    SURGERY. 


The  Best  Methods  of  Securing  Traction  During  Recumbency,  accord- 
ing to  Schapps,  are  illustrated  in  figure  2322.  "A"  represents  a  head-sling 
devised  by  Sayre,  as  already  sketched  in  figure  2298;  "B"  consists  of  a 
single  piece  of  non-elastic  webbing  constructed  with  one  buckle  and  two 
rings.  Where  necessary,  it  may  be  supplied  with  a  chin-piece,  which  ex- 
tends from  one  ring  to  the  other,  passing  under  the  chin.  "C"  exhibits  a 
non-elastic  band  with  two  rings. 

Schapps'  Garment  for  patients  with  spinal  curvature,  as  outlined  in  figure 
2323,  practically  consists  of  an  apron  without  a  back.  It  is  provided  with 
sleeves  and  a  neck-piece  by  which  it  is  held  in  position.  The  flowing  sides 
may  be  tucked  under  the  patient,  or  secured  to  the  under  sheet  with  safety- 
pins.  The  second  figure  shows  a  pattern  from  which  it  may  be  made. 

Spinal  Cuirass. 

Rest  in  a  recumbent  position  may  also  be  maintained  by  the  use  of  a 
cuirass.  This  consists  of  a  strong  wire,  curved  frame,  of  such  size  and 
shape  as  to  form  a  trough-shaped  bed  in  which  the  patient  may  lie. 
Usually  they  are  carefully  padded  and  may  be  constructed  with  jury  masts 
and  other  mechanism  for  securing  traction  and  fixation. 


Figure  2334.     Sayre's  Wire  Cuirass. 


Sayre's  Cuirass,  as  signified  in  figure  2324,  will  secure  rest  and  a  proper 
position.  It  consists  of  a  strong  wire  netting,  well  padded  inside.  The 
patient  is  firmly  bandaged  to  it  with  the  anus  opposite  the  opening.  Ban- 
dages are  carried  under  the  perineum,  and  extensions  made  by  screws  at 
the  foot.  After  operation  on  the  hip-joint,  this  apparatus  will  be  found 
valuable  as  a  means  of  fixation,  and  the  patient  may  be  carried  about  or 


LORDOSIS.  971 

taken  out-of-doors  with  perfect  safety.  In  some  cases  a  jury  mast  attach- 
ment will  be  found  of  value.  This  cuirass  is  also  used  by  Sayre  in  treating 
Pott's  disease. 


LORDOSIS. 

This  form  of  antero-posterior  curvature,  whether  the  result  of  tubercu- 
losis, or  paralysis,  or  acquired  from  posture,  occupation  or  other  cause,  may 
be  relieved  by  various  methods,  among  which  are  braces  and  jackets.  The 
latter  do  not  differ  from  those  used  for  Pott's  disease  and  described  by  fig- 
ures 2299  to  2304. 

Lordosis  Braces. 

These  are  constructed  with  a  pelvic  band  and  upright  in  the  ordinary 
form,  differing  only  in  the  arrangement  of  pressure  points.  In  these  cases 
the  fulcrum  consists  of  an  abdominal  band  or  apron  placed  anteriorly, with 
counter-pressure  by  pads  on  the  sacrum  and  scapulae. 


Figure  2325.     Bradford's  Brace  for  Lordosis. 

Bradford's  Brace  for  Lordosis,  as  traced  in  figure  2325,  consists  of  a 
neck-band  to  which  an  upright  is  firmly  secured  by  a  wide  metallic  plate. 
The  latter  consists  of  a  strong  steel  bar,  to  the  upper  surfaces  of  which  axillary 
crutches  are  attached.  Each  of  these  is  made  of  a  single  piece  curved  to  pass 
over  the  scapula  and  thence  forward  to  include  the  shoulder.  A  broad  ab- 
dominal band  attached  to  a  curved  cross-piece  encircles  the  body  at  a  point 
about  opposite  the  lower  ribs.  As  the  hip-band  is  broad  and  rests  evenly 
on  the  iliac  crests,  a  certain  degree  of  suspension  may  thus  be  secured  if  the 
axillary  crutches  are  properly  adjusted. 


ROUND-SHOULDERS. 

Except  possibly  as  reminders  to  assume  a  proper  position,  the  ordinary 
shoulder  braces  of  the  market  are  practically  worthless.  Their  use,  if  con- 
tinued for  any  length  of  time,  unless  counteracted  with  properly  advised 
gymnastics,  results  only  in  weak  and  impaired  muscles.  These  appliances 
should  be  superseded  by  proper  gymnastics  and  a  discontinuance  of  im- 


972 


ORTHOPEDIC    SURGERY. 


proper  attitudes.  In  severe  cases,  where  mechanical  aid  is  necessary  for 
the  reduction  of  any  kyphosis,  some  form  of  light  spinal  brace  is  advised. 
These,  to  be  efficient,  must  be  constructed  with  pelvic  bands,  perpendicular 
supports  and  shoulder  straps,  the  whole  so  adjusted  as  to  reinforce  the 
weakened  muscles  and  secure  a  proper  position  to  the  patient. 


Figure  2326.    Nyrop's  Shoulder  Brace. 


Figure  2327.     Stillman's  Brace  for  Round  Shoulders. 


Nyrop's  Shoulder  Brace,  as  shown  in  figure  2326,  consists  of  a  pelvic 
band  or  belt  to  which  is  attached  a  spring-steel  upright,  so  shaped  as  to 
correct  any  upper  dorsal  anterior  flexion.  A  clavicular  cross-piece  termi- 
nates at  each  end  in  a  round  axillary  strap  and  is  secured  anteriorly  by  bands 
extending  across  the  chest  and  over  the  shoulder  where  they  are  attached 
to  an  upright.  This  apparatus  does  not  compress  the  thorax,  is  light  and 
does  not  tend  to  disfigure  the  clothing. 

Stillman's  Shoulder  Brace,  as  traced  in  figure  2327,  consists  of  a  hip- 
band,  to  which  is  attached  a  pair  of  padded  strips,  one  on  each  side  of  the 
median  line,  so  as  to  avoid  the  spinous  processes.  These  strips  extend 
upward  to  the  middle  dorsal  region,  terminating  in  a  pressure-pad.  To 
effect  this,  a  light  steel  frame  molded  to  the  shape  of  the  back,  and  extend- 
ing from  the  sacrum  to  the  cervical  vertebrae  is  attached  at  its  lower 
extremity  to  the  hip-girth,  and  there  provided  with  ratchets,  which  admit 
of  its  being  secured  at  any  angle.  The  upper  extremity  of  this  frame  is 
secured  to  the  body  by  means  of  axillary  crutches,  terminating  in  pads  over 
the  acromion  processes.  In  severe  cases  a  removable  head-piece  may  be 
added.  The  action  of  the  brace  is  that  of  a  lever  so  exerting  its  force  as  to 
distribute  its  pressure  along  the  spine. 


SCOLIOSIS:  ROTARY  LATERAL  CURVATURE. 

While  recognizing  the  great  value  of  gymnastic  exercises,  posture  and 
hygienic  measures  in  the  treatment  of  this  class  of  deformities,  in  the 
proper  scope  of  this  work  we  have  practically  nothing  to  do  with  any  save 
the  mechanical  means  which,  by  various  methods,  are  directed  toward  cor- 
recting the  rotary  displacement. 

This   deformity   is   difficult   to  treat  successfully,   principally  for    the 


SCOLIOSIS. 


973 


reason  that  the  causative  force,  that  is,  the  improperly  balanced  weight  of 
the  superincumbent  parts  rests  directly  on  the  curved  spine,  while  the 
curative  agent  must  exert  pressure  only  on  the  ribs.  In  severe  cases  the 
surgeon  can  only  hope  to  prevent  an  increase  in  the  curvature. 

Mechanical  treatment,  whether  employed  simply  to  correct  faulty  atti- 
tudes or  directed  toward  untwisting  the  curves,  may  be  secured  by  meth- 
ods and  appliances  so  numerous  that  it  would  be  useless  to  attempt  to  incor- 
porate all  in  this  chapter.  Among  these  methods  and  forms  of  appliances 
we  have  selected  the  following: 

Appliances  for  recumbency,  appliances  for  suspension,  inclined  seat- 
plane,  crutches,  jackets,  corsets,  braces,  and  immediate  correction  apparatus. 

Treatment  by  Recumbency  and  Suspension  does  not  differ  materially  from 
the  methods  previously  described  in  this  chapter. 

Inclined  Seat-Plane. 

The  Inclined  Seat-Plane  is  employed  only  in  slight  lumbar  curvatures, 
or  those  in  the  lower  dorsal  region. 


Figure  2328.     Volkmann's  Oblique  Seat. 


Figure  2329.    Crutch  for  Lateral  Curvature. 


The  Inclined  Seat  most  common  in  use  is  pictured  in  figure  2328.  While 
seats  for  this  purpose  may  be  improvised  from  a  piece  of  board  raised 
at  one  edge,  many  patients  prefer  an  adjustable  seat  that  can  be  changed 
in  its  angle  of  inclination. 

The  Volkmann  pattern  consists  of  two  parts,  one  resting  above  the 
other,  the  two  being  hinged  on  one  side,  while  the  opposite  is  provided 
with  a  ratchet  and  catch  by  means  of  which  any  degree  of  obliquity  may 
be  obtained  and  maintained.  The  upper  surface  may  be  padded  and 
covered  with  any  material  desired.  They  are  employed  to  prevent  or  over- 
come tilting  of  the  pelvis. 

Crutches  for  Lateral  Curvature. 

Crutches  attached  to  pelvic  bands  are  sometimes  employed  in  slight 
cases,  particularly  if  the  deformity  is  in  the  middle  or  lower  dorsal  region. 
They  are  used  only  in  slight  cases  where  the  correction  of  a  faulty  attitude 
is  desired. 


974 


ORTHOPEDIC    SURGERY. 


The  Crutch  for  Lateral  Curvature,  portrayed  in  figure  2329,  consists  of 
a  well-padded  crutch,  supplied  with  means  for  extension  and  attached  to  a 
belt  encircling  the  pelvis.  This  may  be  supplemented  by  a  wide  band 
or  apron  encircling  the  trunk,  a  portion  of  which  may  be  elastic. 

Jackets  for  Lateral  Curvature. 

Jackets  are  more  largely  employed  because  of  the  popular  idea  that  they 
are  more  effective.  Their  value,  however,  is  questionable,  regardless  of 
the  material  from  which  they  may  be  constructed.  They  may  be  manu- 
factured and  applied  in  the  manner  described  in  the  section  devoted  to 
Pott's  disease.  As  a  rule,  they  act  rather  as  a  check  to  increased  curva- 
ture or  reminder  of  the  correct  position  to  be  assumed,  than  as  curative 
agencies.  They  are  objected  to  because  the  spinal  muscles  are  limited  in 
their  action,  the  respiration  impaired,  active  exercise  prevented,  and 
because  the  upper  portion  of  the  spine  can  not  be  controlled.  When 
employed,  they  should  extend  to  as  low  a  point  on  the  hips  as  the  comfort 
of  the  patient  in  a  sitting  posture  will  admit.  To  be  at  all  efficient  they 
must  fit  the  hips  snugly,  in  order  to  secure  a  firm  grasp  either  as  a  support 
for  crutch  extension  or  to  procure  a  base  for  counter- rotation.  Where  the 
patient  leans  to  one  side,  lateral  supports  in  the  form  of  strong  stays  and 
crutches  are  indicated. 

Corsets  for  Lateral  Curvature. 


Figure  2330.    Beeley's  Spinal  Corset. 

Corsets  for  Lateral  Curvatures  do  not  differ  materially  from  those 
previously  described,  particularly  when  manufactured  from  plaster  of  paris, 
leather,  etc. 


SCOLIOSIS. 


975 


Beeley's  Spinal  Corset,  as  illustrated  in  figure  2330,  has  been  very  satis- 
factory where  the  surgeon  has  succeeded  in  having  it  properly  made  and 
accurately  fitted  to  the  patient.  It  can  be  used  in  the  treatment  of  either 
scoliosis  or  kyphosis,  though  Beeley  recommends  it  particularly  for  the 
former  deformity.  It  is  formed  upon  a  cast  of  the  patient,  which  should  be 
made  while  the  patient  is  suspended,  or  it  is  fitted  to  the  patient  himself, 
when  convenient.  The  appliance  is  made  of  strong  cloth  and  spring-steel, 
except  in  the  pelvic  portion,  where  the  steel  should  be  malleable.  It  is 
arranged  to  lace  front  and  back,  admitting  of  easy  application  and  removal. 
Axillary  crutches  support  the  trunk.  Careful  fitting  over  the  hips  gives 
a  good  foundation  for  a  proper  corrective  force. 

Braces  for  Lateral  Curvature. 

These  are  constructed  to  secure  lateral  pressure  by  leverage.  This 
force  should  be  so  directed  as  to  tend  constantly  toward  returning  the  dis- 
torted vertebrae  to  their  normal  position.  Such  leverage  may  be  supple- 
mented when  necessary  by  removing  the  superimposed  weight  and  furnish- 
ing support  for  the  weakened  spinal  column.  They  usually  consist  of  some 
form  of  a  pelvic  band  or  support,  so  adjusted  as  to  fit  firmly  and  snugly  on 
the  pelvis,  that  this  may  be  used  as  a  fixed  point  from  which  to  secure 
counter-rotary  motion.  The  pelvic  bands  should  be  in  dome- form,  fitting 
closely  over  the  iliac  crests,  or  fixation  may  be  secured  and  tilting  of  the 
pelvis  prevented  by  perineal  bands  or  straps.  When  properly  applied,  they 
should  check,  if  not  diminish  the  amount  of  displacement.  The  only 
objections  are  that,  as  usually  manufactured,  they  are  cumbersome,  and, 
as  compared  with  many  other  methods  of  treatment,  expensive.  Ordina- 


Figure  2331.     Harwell's  Strap  and  Band 
Brace  for  Lateral  Curvature. 


Figure  2332.     Rotary  Lever  Brace. 


rily  they  are  constructed  on  one  of  three  principles ;  straps  and  buckles, 
pads  or  arms  controlled  by  screw,  and  levers. 

Strap  and  Buckle  Braces  to  secure  the  necessary  pressure  are,  as  a  rule, 
the  least  effective  among  this  class  of  apparatus.      At  best  they  act  more 


976  ORTHOPEDIC    SURGERY. 

as  reminders  to  assume  a  correct  position  than  as  corrective  apparatus. 
They  are  usually  simpler  in  construction  and  consequently  less  expensive 
than  other  forms  of  braces. 

Harwell's  Strap  and  Band  Brace  for  Lateral  Curvature,  as  portrayed 
in  figure  2331,  consists  of  an  oblong  crutch-pad  of  firm  sole  leather  in 
trough-like  form,  its  concave  surface  fitted  to  the  trunk  under  the  axilla 
of  the  depressed  or  lowered  shoulder.  The  upper  margin  should  be  con- 
cave like  a  crutch-top,  that  it  may  rest  closely  in  the  axillary  space.  The 
lower  corners  of  this  pad  are  connected  by  a  band  passing  front  and  back 
over  the  opposite  shoulder,  on  the  crest  of  which  a  cup-shaped  pad  is  placed. 

From  the  two  upper  corners,  bands  descend  front  and  back,  to  a  pad 
placed  over  the  opposite  hip,  to  which  they  are  fastened  at  the  upper  cor- 
ners. The  lower  corners  of  this  hip-pad  are  secured  by  a  perineal  strap. 
From  the  center  of  the  crutch-pad  a  band  passing  around  the  chest,  rests 
under  the  opposite  shoulder  on  a  small  pad  placed  directly  opposite  the 
larger  one.  This  is  held  in  place  by  straps  suspended  by  a  shoulder  strap. 
The  lower  corners  of  this  infra-axillary  pad  are  connected  with  a  fifth  pad 
placed  over  the  prominent  iliac  crest.  This  is  also  held  in  place  by  means 
of  a  perineal  band.  These  bands  or  straps  are  in  most  cases  elastic,  thus 
exerting,  when  correctly  applied,  a  constant  pressure.  In  action,  the  depend- 
ent shoulder  is  really  suspended  by  its  fellow,  the  whole  arrangement  being 
calculated  to  untwist  existing  rotary  displacement.  The  principal  advan- 
tage of  this  brace  lies  in  its  moral  effect  on  the  patient.  When  strapped 
tightly  enough  to  act  as  a  curative  agent,  the  patient  is  practically 
helpless. 

The  Rotary  Lever  Brace  for  Lateral  Curvature,  shown  in  figure  2332, 
is  one  of  the  simplest  yet  most  efficient  of  the  plain  patterns  of  braces. 
It  consists  of  a  metallic  frame  in  open  band  form,  encircling  the  trunk  under 
the  axillae  and  connected  by  means  of  an  upright  with  a  pelvic  clamp  so 
adjusted  that  rotary  pressure  is  exerted  on  the  trunk,  the  hips  being 
employed  as  a  base.  The  hip-clamp  is  constructed  much  after  the  pattern 
of  many  double  trusses,  and  is  intended  to  rest  close  to,  and  accurately  fit 
the  form.  By  a  ratchet  and  screw  adjustment  any  desired  amount  of 
leverage  or  counter-pressure  may  be  exerted.  The  metallic  trunk  band 
should  be  well  padded  under  the  axilla  of  the  depressed  shoulder  and 
should  be  flat  across  the  back,  fitting  the  form  closely.  It  is  suitable  only 
for  lower  dorsal  and  lumbar  displacements. 

Taylor's  Lateral  Curvature  Brace,  as  depicted  in  figure  2332A,  consists  of 
a  light  steel  band  encircling  the  hips  just  above  the  level  of  the  trochan- 
ters.  This  band  is  closed  at  one  side  by  a  strap  and  buckle.  An  H- 
shaped  steel  upright  is  firmly  secured  to  it,  and  to  this  a  broad  band  of 
leather  is  fixed  at  right  angles,  the  latter  adjusted  so  as  to  secure  pressure 
against  the  projecting  ribs  on  the  convexity.  This  is  held  in  position  by  a 
flexible  hip-piece  which  fits  closely  over  the  ilium  on  the  side  of  the  prom- 
inent curve,  where  it  is  buckled  to  a  hip-band. 

The  hip-piece  is  attached  to  a  perineal  strap  that  passes  under  the  leg 
on  the  side  opposite  the  main  curve.  This  is  used  as  a  stay  for  the  hip- 
piece  when  the  latter  is  used  as  a  fulcrum  for  counter-rotation. 

Counter-pressure  is  supplied  by  a  similar  firm  leather  band  attached  to 
a  second  H-shaped  piece.  The  two  steel  uprights  are  fastened  together 
in  front  by  an  adjustable  bow-shaped  steel  piece.  This  brace  furnishes 
a  means  for  working  from  fixed  points  on  the  pelvis,  counteracting  the 
swaying  of  the  trunk  to  one  side  en  masse,  one  of  the  greatest  difficulties 


ANKYLOSIS  OF   THE  ELBOW   AND  CONTRACTED  WRIST. 


977 


encountered  in   this  class  of  cases.     This  appliance,   although  somewhat 
complicated,  is  one  of  the  best  of  its  class. 

Tiemann's  Brace  for  Lateral  Curvature,  as  shown  by  figure  2333,  con- 
sists of  a  metallic  pelvic  band,  supporting  crutches  on  each  side,  and  a 
spinal  upright  extending  nearly  to  the  vertebra  prominens.  This  is  sup- 


Figure  2332A.    Taylor's  Brace  for  Lateral 
Curvature. 


Figure  -.3333.    Tiema  --n's  Brace  for  Lateral 
Curvature. 


plied  with  a  cross-bar  attached  opposite  the  centers  of  the  scapulae,  the 
ends  being  protected  with  pads.  Shoulder  straps  connect  these  pads  with 
the  anterior  tips  of  the  crutches.  Pressure  on  the  protruding  ribs  is 
produced  in  a  counter-rotary  direction  by  an  elastic  band  attached  to  the 
upright  at  one  end.  It  is  provided  with  elastic  crutches,  each  made  in  two 
pieces,  and  connected  with  strong  elastic  webbing,  permitting  adjustment 
to  any  desired  height.  These  serve  to  exert  an  elastic  support  under  the 
axillae.  It  may  be  modified  by  employing  but  one  crutch  on  the  depressed 
side,  connecting  this  posteriorly  with  the  scapula  pad.  The  hip-band  is 
made  much  wider,  resting  well  on  the  iliac  crests. 

The  elastic  band,  which  narrows  near  its  extremity,  is  so  carried  as  to 
pass  over  the  opposite  hip,  extending  nearly  around  to  the  upright,  while  a 
brace  extends  from  the  upright  to  the  pelvic  band  that  the  former  may 
withstand  the  lateral  strain  caused  by  the  contractile  force  of  the  elastic 
band. 


ANKYLOSIS    OF   THE   ELBOW    AND   CONTRACTED  WRIST. 

These  complications  may  be  benefited  in  mild  cases  by  some  form  of 
tension  apparatus.  In  severe  cases  but  little  improvement  may  be 
looked  for. 


62 


978  ORTHOPEDIC    SURGERY. 

The  Apparatus  for  Ankylosed  Elbow,  as  illustrated  in  figure  2334,  con- 
sists of  a  broad  band  encircling  the  upper  portion  of  the  arm,  a  second  one, 
somewhat  smaller,  just  below  the  elbow-joint,  and  a  third  of  still  smaller 
proportions,  which  includes  the  wrist.  These  bands  are  connected  with 


Figure  2334.     Apparatus  for  Ankylosed  Elbow.        Figure  2335.     Apparatus  for  Contracted  Wrist. 

steel  bars  parallel  with  the  arm  and  supplied  with  joints  at  the  elbow.  The 
joints  are  arranged  with  a  circular  ratchet  and  endless  screw  by  which 
forcible  extension  may  be  secured.  This  form  of  appliance  is  useful 
because  by  its  means,  full  flexion  or  extension  may  be  secured. 

The  Apparatus  for  Contracted  Wrist,  the  action  of  which  is  made  clear 
by  figure  2335,  is  intended  for  correcting  cases  of  flexed  wrists,  caused 
either  by  muscular  contraction  or  by  partial  ankylosis. 

The  illustration  fully  shows  the  manner  in  which  force  is  applied.  When 
well  fitted,  reasonably  good  results  can  be  expected  from  the  appliance. 


HIP-JOINT  DISEASE. 

Diseases  of  the  hip-joint  may  be  treated  by  measures  either  conservative 
(mechanical)  or  radical  (operative).  Appliances  for  the  latter  procedures 
will  be  found  described  under  the  heading  of  Bone  Surgery.  The  mechan- 
ical methods  may  be  classified  as  fixation,  to  secure  rest;  traction,  to 
obtain  extension,  and  protection,  to  guard  against  further  deformity 

Fixation. 

Fixation,  or  joint  immobilization,  may  usually  be  secured  by  plaster  of 
paris  bandages,  metallic  cuirass  and  metallic  splints. 

Plaster  of  Paris  Splints  furnish  an  imperfect  means  of  fixation,  and  are 
usually  employed  only  as  a  temporary  means,  or  when  necessary  in  charity 
cases.  They  are  also  uncleanly  and  but  slightly  corrective. 

The  Wire  Cuirass,  shown  by  figure  2324,  supplies  excellent  fixation.  It 
is  objectionable,  however,  because  of  its  high  price,  weight  and  general 
awkwardness.  In  cases  of  hip-joint  disease  it  should  usually  be  fitted 
with  means  for  direct  and  counter-traction. 

Thomas'  Splint,  as  defined  by  figure  2336,  is  one  of  the  most  simple  of 
fixation  appliances,  and  yet  none  is  more  satisfactory.  It  consists  of  an 
upright  flat  metallic  bar  to  which  are  attached  three  metal  bands,  one 
partially  encircling  the  leg  just  below  the  calf,  a  second  passing  nearly 
around  the  thigh  just  below  the  ischium,  and  the  third  encircling  the  trunk, 
close  under  the  axillae.  It  is  intended  to  immobilize  the  hip-joint,  and  will 
secure  this  condition  when  properly  applied.  The  body  and  leg  portions  of 
the  brace  are  straight  and  on  parallel  lines,  the  center  being  curved  in 
bayonet  form.  The  amount  of  this  curvature  depends  on  the  contour  of 
the  patient. 

When  rest  in  a  recumbent  position  is  advised,  patients  may  be  pre- 
vented from  getting  up  by  fastening  to  the  main  brace  an  extension,  or 


HIP-JOINT    DISEASE. 


979 


"nurse,"  as  it  has  been  named,  as  shown  in  the  illustration.  This  should 
be  so  arranged  as  to  be  fastened  with  screws  or  bolts,  and  should  be  long- 
enough  to  extend  twelve  to  fifteen  inches  below  the  bottom  of  the  foot. 
The  splint  should  be  manufactured  from  soft  tenacious  iron,  so  that  it  can 
be  molded  to  the  parts  by  the  surgeon.  It  should  be  applied  with  the 


Figure  2336.     Thomas'  Hip-Splint. 


Figure  2337.     Extension  or 
Nurse  for  Thomas' 
Splint. 


Figure  2338.     Thomas'  Splint 
Applied 


patient  supine.  The  bands  should  be  spread  sufficiently  to  admit  of  their 
being  passed  around  the  patient  from  the  affected  side,  after  which  they 
may  be  bent  so  as  to  closely  fit  the  parts  by  means  of  suitable  wrenches, 
such  as  are  described  by  figures  2284  and  2285.  In  cases  of  adduction  or 
abduction  an  extra  wing  or  half-body  band  is  often  employed.  The  splint 
should  be  padded  and  covered  with  leather  throughout  its  entire  length. 
In  charity  patients,  instead  of  this  cover,  it  may  be  wrapped  with  strips  of 
cotton  flannel,  after  first  being  covered  with  sheet  wadding,  the  latter  to 
prevent  absorption  of  perspiration. 

The  sizes  of  material  advised  by  Ridlon  for  the  manufacture  of  Thomas' 
splint  are: 

For  largest  adult         i  %  inches  wide,  %  inch  thick. 
"    small  i#      "          "       jV     "       " 

' '    youth 


child  of  10  years     y± 


The  bands  should  be  of  the  same  width  as  the  main  brace,  but  of  such 
thickness  that  they  may  be  bent  with  the  hands. 

Traction. 

The   value  of  traction  is  somewhat  doubtful.       Its  beneficial  results, 
aside  from  the  rest  secured  in  connection  with  it,  are  questionable.     It  is 


980 


ORTHOPEDIC    SURGERY. 


employed  by  some  physicians  as  an  aid  to  immobilization,  by  others  to 
prevent  it. 

Splints  for  producing  traction  consist  of  means  for  pulling  or  drawing 
and  maintaining  the  head  of  the  femur  away  from  the  acetabulum.  Usu- 
ally the  leg  is  fastened  to  some  form  of  a  splint  that  extends  above  the 
trocanter,  counter-pressure  or  resisting  force  being  supplied  by  straps 
beneath  the  perineum.  A  sliding-joint  forms  a  portion  of  the  mechanism 
of  most  instruments.  This  is  generally  arranged  with  some  form  of  a 
rachet  secured  by  a  spring,  so  that  any  amount  of  converging  force  desired 
may  be  secured  and  indefinitely  maintained.  Usually  these  splints  present 
some  modified  form  of  the  original  Davis  pattern.  They  consist  of  steel 
shafts  extending,  as  a  rule,  from  the  trocanter  to  the  sole  of  the  foot,  means 
being  provided  for  extending  or  elongating  the  upright  after  it  is  secured 
in  proper  pDsition.  The  upper  end  is  jointed  to  a  metal  pelvic  band  to 
which  one  or  more  perineal  straps  are  attached.  The  lower  ends  are 
generally  curved  under  the  foot  and  provided  with  means  for  attachment 
to  the  limb  by  adhesive  plasters,  shoes  or  bandages. 

The  regulation  of  the  traction  force,  and  the  adjustment  of  the  splint  to 
varying  lengths  of  limb  are  secured  by  some  form  of  extension  support. 


Figure  2*39.     Sayre's  Long  Hip-Splint. 


Figure  2340.     Ridlon's  Traction  Hip-Splin.. 


Usually  this  consists  of  a  bar  or  rod  provided  with  transverse  teeth  cut 
along  one  side^  the  serrated  portion  sliding  within  a  tube,  in  which  a  spring 
secures  the  two  parts  in  any  desired  position.  Elongation  of  the  tube  may 
be  secured  by  means  of  a  pinion  or  cog  wheel  operated  by  a  crank  or  key. 


HIP-JOINT    DISEASE.  981 

Other  forms  are  constructed  with  a  wooden  bar  and  a  windlass,  while  still 
simpler  ones  are  made  with  elastic  cords  or  bands. 

Sayre's  Hip-Splint,  as  described  by  figure  2339,  extends  from  the  sole 
of  the  foot  to  the  crest  of  the  ilium,  at  which  point  it  is  connected  to  a 
pelvic  band,  a  joint  allowing  flexion  and  extension,  abduction  and  adduc- 
tion. These  latter  motions  are  regulated  by  a  thumb-screw. 

Extension  is  secured  by  a  rack  and  pinion  rod.  The  latter,  sliding  in  a 
steel  tube,  is  moved  by  a  key  and  held  in  position  by  a  spring  secured  by 
iwo  perineal  pads  fastened  to  the  pelvic  band  with  straps  and  buckles.  A 
movable  cross-piece  serves  at  the  knee-joint  for  the  attachment  of  a  leather 
cap,  used  to  steady  and  support  the  knee.  A  foot-piece,  with  a  leather 
sole,  at  the  bottom  of  the  instrument  prevents  jar  in  walking.  A  leather 
strap  passes  under  the  foot,  through  apertures  in  the  foot-piece.  The 
ends  of  this  strap  extend  upward  on  each  side  of  the  ankle  and  are  attached 
to  buckles  in  adhesive  strips  that  are  attached  to  the  leg. 

Ridlon's  Traction  Hip-Splint,  shown  in  figure  2340,  is  similar  to  the 
other  long  traction  splints,  with  the  addition  of  a  chest-band.  The  bar 
connecting  the  chest-band  with  that  encircling  the  pelvis  and  main  upright 
is  riveted  firmly  to  the  thoracic-piece  but  bolted  to  the  pelvic  band.  The 
bolt  is  strong  and  half  an  inch  in  diameter  with  a  round  and  a  square  portion, 
conforming  respectively  to  the  round  holes  in  the  upper  bar  and  pelvic 
band,  and  to  the  square  hole  in  the  main  upright.  A  hold-back  strap  is  used 
to  prevent  undue  tilting  of  the  pelvic  band  when  the  splint  is  worn  in  conval- 
escence. This  appliance  may  be  converted  into  the  ordinary  long  traction 
splint  by  removing  the  part  above  the  pelvic  band.  The  special  advantage 
in  this  splint  is  its  adaptability  in  cases  where  the  thigh  is  flexed  on  the 
pelvis. 

Judson's  Hip-Splint  as  depicted  in  figure  2341,  is  constructed  so  as  to 
extend  from  just  below  the  sole  of  the  foot  to  a  point  between  the  great 
trochanter  and  the  iliac  crest.  The  upright  consists  of  two  parts,  the  lower 
playing  into  the  upper,  with  rack  and  key  for  altering  its  length.  A  bolt 
locks  the  upright  to  the  pelvic  band  at  the  angle  at  which  the  splint  is 
adjusted  by  the  surgeon.  A  knee-piece  steadies  the  thigh  antero-posteri- 
orly,  arresting  motion  at  the  hip-joint.  This  knee-piece  is  easily  bent  to 
conform  closely  to  the  limb.  It  can  be  moved  up  or  down  on  the  upright 
and  should  be  fastened  just  above  the  knee.  A  strong  webbing  strap,  not 
shown  in  the  figure,  is  buckled  just  above  this  piece  to  steady  the  thigh 
laterally.  A  leather  strap  encircles  the  leg  and  the  upright  above  the 
ankle-joint,  keeping  the  foot  near  the  splint  in  walking.  A  strong  webbing 
strap  passes  over  the  pelvic  band,  under  the  upright  and  over  the  opposite 
shoulder  to  carry  the  weight  of  the  splint  when  the  patient  walks.  It 
should  be  buckled  just  tight  enough  so  that  the  patient  can  feel  the  weight 
of  the  splint  on  the  shoulder  of  the  well  side  when  he  advances  the  affected 
limb  in  walking.  The  shoulder  strap  is  to  be  loosened  or  removed  at 
night.  The  perineal  strap  has  a  loop  at  each  end,  which  passes  over  the 
screw,  by  which  it  is  kept  in  place.  By  loosening  the  nut,  the  pelvic  band 
may  be  adjusted  at  the  desired  angle  with  the  upright,  where  it  should  be 
fixed  by  tightening  the  nut.  The  splint  is  shod  with  sole-leather.  A 
leather  strap  passing  under  the  foot  through  apertures  in  the  foot-piece  is 
turned  up  on  each  side  of  the  ankle  and  fastened  to  buckles  on  adhesive 
strips,  with  the  heel  fully  clearing  the  foot-piece.  The  length  of  the  splint 
is  readily  altered,  and  the  position  of  the  pelvic  band  at  a  level  between 
the  iliac  crest  and  the  trochanter  is  determined  by  the  length  of  the  perineal 


982 


ORTHOPEDIC    SURGERY. 


strap.     This  splint  can  also  be  made  with  a  complete   pelvic  band  and  two 
perineal  straps,  if  the  surgeon  so  desires. 

Protection. 

Protection  serves  to  prevent  further  deformity  by  overcoming  muscular 
contraction  and  injurious  jar  upon  the  affected  joint.     It  may  be  secured 


Figure  2311.    Judson's  Hip-Splint. 


Figure  2342.    Ridlon's  Protective  Hip-Splint. 


by  an  extension  under  the  sound  limb  and  the  constant  use  of  crutches,  or 
by  use  of  a  long-  splint  without  traction. 

Ridlon's  Hip-Splint  for  Rotation,  as  pictured  in  figure  2342,  differs 
from  the  pattern  of  Thomas  in  combining  a  lateral  axillary  support  that 
may  be  used  as  a  means,  not  only  of  securing  partial  extension,  but  to 
steady  and  immobilize  the  limb.  This  upright  at  its  base  is  attached  to  a 
somewhat  circular  band  that  encircles  the  posterior  aspect  of  the  limb  just 
above  the  knee.  It  is  attached  to  the  outer  margin  of  the  obliquely- 
placed  perineal  ring.  Its  upper  extremity  is  attached  to  a  circular  axillary 
band  in  truss  form. 

When  applied,  the  whole  is  padded  by  being  wound  with  strips  of 
cotton  flannel,  the  ends  of  the  axillary  band  being  united  by  the  same 
means. 

PARALYSIS  OF  LOWER  LIMBS. 

Splints  made  to  embrace  and  support  the  lower  limbs  may  be  arranged 
for  one  or  both  legs  and  with  single  or  double  side-bars  as  desired.  If 
braces  for  both  legs  are  required,  they  may  be  independent  or  attached  to  a 
pelvic  band.  They  may  be  manufactured  stiff  or  jointed  as  the  peculiarities 


KNEE-JOINT    AFFECTIONS. 


983 


of  the  case  in  hand  may  demand.  Frequently  they  are  constructed  with 
adjustable  knee-joints.  These  may  be  allowed  to  move  freely  or  may  be 
provided  with  locks  that  transform  them  into  stiff  bar-braces.  Steele 
employs  firm  leather  casings  shaped  over  plaster  casts. 


Figure  2348.    Plain  Brace  with- 
out Joints  for  Paralysis 
of  Leg. 


Figure  2344.    Jointed  Brace 
for  Weak  Leg. 


Figure  2345.    Jointed  Double  Brace 
for  Partial  Paralysis  of  the 
Lower  Limbs. 


The  Plain  Brace,  without  Joints,  for  Paralysis  of  the  Leg,  shown  by  figure 
2343,  consists  of  a  steel  bar  extending  laterally  from  a  point  opposite  the 
ischium  down  to  and  under  the  foot,  and  up  along  the  inside  of  the  leg  to 
the  perineum.  The  top  is  held  in  place  by  a  wide  steel  thigh-band,  while  a 
similar  band  placed  over  the  knee  prevents  flexion.  The  brace  should  be 
attached  at  the  bottom  to  the  sole  of  a  shoe.  This  effectually  prevents 
flexion  of  the  knee,  answering  the  practical  purpose  of  locomotion.  In  cases 
where  the  knee  recedes  backward  and  becomes  hyper-extended,  a  back- 
band  will  be  also  required. 

The  Jointed  Brace  for  Weak  Leg,  delineated  by  figure  2344,  is  applicable 
in  cases  of  wasting  palsy,  or  when  certain  groups  of  muscles  become 
atrophied,  losing  the  power  to  perform  their  functions.  The  muscles  are 
excited  to  action,  and  are  aided  by  artificial  substitutes  made  of  elastic 
rubber  or  steel,  placed  on  the  instrument  so  as  to  gently  exercise  the  affected 
parts. 

The  Double  Brace  for  Paralysis,  shown  in  figure  2345,  is  one  of  many 
patterns  designed  for  use  in  cases  of  paraplegia  or  where  from  any  cause 
there  is  an  inability  on  the  part  of  the  patient  to  sustain  the  body  weight. 


KNEE-JOINT  AFFECTIONS. 

Diseases  of  the  knee-joint  require  fixation  appliances,  protective  appli- 
ances and  mechanism  to  overcome  ankylosis. 

Fixation  Appliances  are  principally  employed  in  cases  of  synovitis, 
tubercular  affections,  etc.  They  may  be  made  with  or  without  traction. 
They  consist  of  splints  so  adjusted  as  to  prevent  movement  in  the  joint. 
Usually  plaster  of  paris,  silicate  of  soda  or  leather  are  used  for  this  purpose. 


984  ORTHOPEDIC    SURGERV. 

Hoadley's  Knee-Splint,  as  illustrated  in  figure  2346,  consists  of  two  gut- 
ter-shaped sections  of  such  form  and  size  as  to  embrace  the  leg  above  and 
below  the  knee,  the  two  being  united  and  braced  by  a  series  of  slotted  bars 
so  arranged  that  they  may  be  secured  in  any  desired  position  or  angle,  one 
with  the  other.  The  thigh  section  terminates  in  a  T-shaped  bar,  the  upper 
angle  of  which  is  slotted, while  the  lower  is  provided  with  a  post  with  nut 


Figure  2346.     Hoadley's  Knee-Splint. 

and  screw.  The  tibial  section  is  provided  with  a  straight  extension,  the 
projecting  portion  of  which  is  slotted.  The  latter  is  united  with  the  slotted 
portion  on  the  T-shaped  bar  with  a  movable  post  and  screw,  so  that  the  two 
may  be  locked  together  at  any  point  or  angle.  A  slotted  cross-bar  unites 
this  section  with  the  lower  angle  of  the  T-shaped  bar,  fixation  being  secured 
by  a  screw.  The  upper  and  lower  sections  are  of  metal  and  perforated. 
Rotation  of  one  segment  on  the  other  can  be  obtained  as  can  also  lateral 
deviation  The  tension,  traction,  angle  of  flexion  or  the  direction  of  force 
either  forward  or  backward  at  the  upper  end  of  the  tibia  in  its  relation  to 
the  femur  can  be  instantly  and  readily  changed.  In  resections  of  the  joint, 
the  bones  can  be  placed  and  firmly  held  in  contact  at  any  angle.  It  is 
well  adapted  for  correcting  false  positions  and  admits  of  inspection  of  the 
parts. 

Thomas'  Knee-Splint,  as  illustrated  in  figure  2347,  is  made  in  two  forms; 
the  bed-splint  and  the  walking  or  "caliper"  splint  shown  in  the  illustration. 
The  bed-splint  extends  some  distance  below  the  foot  in  an  indented  loop. 
This  form  of  splint  is  readily  transformed  into  the  caliper  form  by  cutting 
off  the  loop  and  bending  the  cut-off  ends  at  a  right  angle  to  pass  into  a  hole 
through  the  heel  of  the  shoe.  The  bed  splint  is  used  only  when  it  is  thought 
best  to  correct  a  deformity  gradually,  by  traction,  or  when,  for  any  reason, 
it  is  desired  to  confine  a  patient  in  bed. 

The  caliper  splint  consists  of  a  ring  and  two  side-bars  of  iron  rods.  The 
ring  slopes  from  without  inward,  and  from  before  backward,  so  that  the 
section  upon  which  the  tuberosity  of  the  ischium  rests  is  its  lowest  part ;  it  is 
bent  to  such  a  shape  that,  when  properly  padded,  it  should  fit  the  outline  of 
the  upper  thigh,  following  the  gluteo-femoral  crease  and  the  groin.  The 
ring  is  padded  with  felt  and  covered  with  basil  leather.  The  side-bars  should 
not  be  bent  if  this  can  be  avoided;  in  some  cases,  however,  it  will  be  neces- 
sary to  curve  the  bar  opposite  the  knee  At  the  back  of  the  knee  is  a  broad 
leather  strap,  and  at  the  back  of  the  ankle  a  second  strap.  Above  and  below 
the  knee  in  front  are  padded  pieces  of  sheet  iron,  by  which  backward  pres- 
sure is  made  by  means  of  a  strip  of  bandage  tied  around  the  side-bars. 

Protective  Appliances  should  be  employed  when  walking  is  permitted. 
They  consist  not  only  in  fixing  the  joint  and  thus  preventing  motion,  but 
in  relieving  it  from  carrying  the  weight  of  the  body.  This  necessitates 
placing  a  shoe  extension  under  the  sound  limb  and  requiring  the  patient  to 
use  crutches.  This  treatment  is  often  maintained  after  complete  fixation, 
during  the  acute  stage,  has  been  discontinued. 


KNEE-JOINT    AFFECTIONS. 


985 


Taylor's  Apparatus  for  Osteitis  of  the  Knee,  as  represented  in  figure 
2348,  consists  of  a  lock-joint  supporting  splint  that  is  well  adapted  to  secure 
protection.  It  consists  of  lateral  steel  bars  provided  with  concave  thigh  - 
and  leg-pieces  in  trough  form.  It  is  constructed  with  a  substantial  knee- 
joint,  so  controlled  by  spring  mechanism  that  it  may  be  fixed  or  locked  for 


Figure  2347.    Thomas'  Knee-Splint. 


Figure  2348. 


Taylor's  Apparatus  for  Osteitis 
of  the  Knee. 


any  desired  time.  The  lower  bars  reach  slightly  below  the  foot  where  they 
are  attached  to  a  removable  foot-plate  that  may  be  applied  or  removed 
without  disturbing  the  brace.  The  leg- plate  is  riveted  to  a  leather  legging 
that  encircles  the  limb  and  laces  in  front.  Curved  bars  somewhat  in  crutch- 
form  are  attached  to  the  upper  terminals  of  the  brace  to  which  a  perineal 
strap  is  secured.  A  thigh-piece  prevents  the  appliance  from  falling 
backward  while  a  knee-plate  carried  by  a  curved,  protected  steel  band 
inhibits  lateral  motion. 

Mechanism  to  Overcome  Knee-joint  Ankylosis  should  be  directed  toward 
straightening  the  flexed  knee.  It  may  be  attempted  by  traction  in  the 
line  of  the  deformity,  forcible  correction  or  fixation  bandages.  The  latter 
may  be  applied  to  the  flexed  limb  when  it  is  at  its  point  of  greatest  flexion. 
These  may  be  reapplied  from  time  to  time,  and  if  their  use  is  persevered  in, 
gradual  straightening  usually  results. 

Traction  may  be  of  two  forms;  fixed  and  ambulatory. 

Fixed  Traction  may  consist  of  weights  and  pulleys  to  be  applied  in  a 
line  with  the  limb.  This  necessitates  the  placing  of  the  patient  in  bed  dur- 
ing the  continuance  of  treatment.  They  do  not  differ  from  those  employed 
in  the  treatment  of  fractures. 

Ambulatory  Traction  Splints  may  be  constructed  in  a  multiplicity  of 
forms.  They  aim  to  avoid  jar  to  the  limb  while  walking,  as  well  as  to 
secure  a  certain  degree  of  fixation. 

Bradford's  Apparatus,  as  defined  by  figure  2349,  consists  of  two  straight 
lateral  bars  attached  to  the  thigh  by  two  bands,  the  lower  portions  of  the 


986  ORTHOPEDIC    SURGERY. 

bars  extending  below  the  knee  nearly  to  a  line  with  the  ankle.  To  the 
upper  surface  of  the  lateral  bars  opposite  the  knee-joint,  hinged  arms  are 
attached  that  extend  downward  and  are  fastened  by  calf-  and  ankle-bands  to 
the  leg.  Elastic  tension  between  the  lower  portion  of  the  brace  and  the 
hinged  arms  may  be  secured  by  bandages,  spiral  springs  or  elastic  tubing, 


Figure  2349.     Bradford's  Apparatus  for  Gradual  Figure  2350.     Long  Ankylosis  Apparatus. 

Forcible  Straightening  of  Knee-Flexion. 

any  of  which,  when  tightly  drawn,  will  serve  to  gradually  straighten  the 
limb,  thus  correcting  the  deformity.  A  strip  of  heavy  cloth  extending 
along  the  anterior  aspect  of  the  limb  from  above  the  knee  to  the  instep,  is 
employed  by  means  of  straps  to  hold  the  brace  in  proper  position. 

The  Long  Ankylosis  Apparatus,  as  portrayed  in  figure  2350,  consists  of 
two  lateral  bars  jointed  at  the  knee  and  ankle,  to  which  are  attached  three 
metal  troughs  encircling  the  limb  at  the  thigh,  calf  and  immediately  above 
the  ankle.  These  troughs  are  constructed  with  straps  and  buckles  by  which 
they  may  be  closely  fitted  and  secured.  The  apparatus  is  also  supplied 
with  a  knee-cap  provided  with  lateral  straps  by  which  it  may  be  held  in 
position.  The  instrument  may  be  flexed  and  extended  by  a  ratchet  and 
key.  The  appliance  is  well  adapted  for  the  gradual  extension  of  contracted 
muscles  and  for  favoring  the  re- establishment  of  motion  in  cases  of  false 
ankylosis. 


KNOCK-KNEE. 

Mechanical  treatment  aims  at  correcting  this  deformity  by  making  coun- 
ter-pressure on  the  internal  condyles,  using  an  upright  external  lateral  bar 
as  a  base.  It  can  prove  advantageous  only  in  children  and  in  youths  whose 
bones  are  still  soft  and  yielding.  Whatever  form  of  brace  be  em- 
ployed, care  must  be  taken  to  see  that  the  limb  does  not  rotate,  producing 
eversion  of  the  foot.  Braces  jointed  at  the  knee,  as  a  rule,  are  not  as  efficient 
as  stiff  appliances.  Not  only  do  the  joints  become  loose,  but  the  degree  of 
deformity  decreases  during  flexion.  Beeley  advises  shoes  obliquely  cut 
about  0.5  centimeters,  the  lower  surface  projecting  inward. 

The  Plain  Knock-Knee  Brace,  detailed  in  figure  2351,  for  cases  of  double 
deformit3T,  consists  of  two  lateral  bars  with  joints  at  the  ankles,  knees  and 


KNOCK-KNEE. 


987 


hips,  extending  from  the  heels  of  strong-  shoes  to  a  well-padded  pelvic  band. 
The  latter  is  made  in  two  halves  in  order  to  admit  of  adjustment.  The 
tightening  of  the  posterior  buckle  everts  the  toes,  while  tightening  of  the 


Figure  2351.    Plain  Knock-Knee  Brace. 


Figure  2352.     Beeley's  Knock-Knee  Brace. 


anterior  buckle  inverts  them.  A  pair  of  padded  straps  secured  to  each  other 
crosswise,  act  as  shown  in  the  cut.  In  this  manner  they  support  the  heads 
of  the  tibia  and  femur,  while  the  direction  of  force,  when  combined,  is 
outward. 


Figure  2353.    Thomas'  Knock-Knee  Brace. 


Beeley's  Knock-Knee  Brace,  as  set  forth  in  figure  2352,  consists  of  two 
plain  external  lateral  bars  without  joints,  each  extending  from  the  sole  of 
the  foot  to  the  iliac  crest.  Each  at  its  upper  margin  is  supplied  with  a 
curved  metallic  pad,  the  two  forming  portions  of  a  band  that  encircles  the 


988 


ORTHOPEDIC    SURGERY. 


waist  at  this  point.  The  apparatus  may  be  firmly  attached  to  the  feet  by 
sole-plates  and  straps.  The  corrective  force  at  the  knees  may  be  applied 
by  bandages  or  straps.  The  latter  should  be  used  in  connection  with 
leather  pads  that  form  the  contact  surfaces  on  the  inner  aspects  of  the  limbs. 
Thomas'  Knock-Knee  Brace,  as  may  be  seen  by  consulting  figure  2353, 
extends  from  the  great  trochanter  to  the  sole  of  the  foot.  A  band  passes 
two  thirds  around  the  upper  thigh,  a  second  one  two  thirds  around  the 
ankle,  the  two  being  connected  by  a  light  posterior  bar.  At  the  top  is  a 
lateral  oblong  pad,  and  at  the  bottom  the  main  side-bar  is  forged  round, 
bent  at  a  right  angle  and  inserted  into  a  hole  in  the  side  of  the  heel  of  the 
shoe.  The  correction  of  the  deformity  is  effected  by  a  roller  bandage. 
The  braces  are  to  be  worn  continuously  night  and  day,  and  when  rapid  cor- 
rection is  desired,  the  patient  is  not  permitted  to  walk  until  the  legs  are 
straight.  The  advantage  claimed  for  this  brace  is  that  it  keeps  the  knee  at 
full  extension  and  thereby  continuously  maintains  full  leverage  action,  an 
advantage  which  is  lost  in  all  jointed  braces,  as  soon  as  the  knee  begins  to 
bend.  The  brace  should  be  made  of  soft  iron. 


BOW-LEGS. 


The  mechanical  treatment  of  bow-legs  consists  in  directing  a  suitable 
lateral  force  against  the  outer  convex  surface  of  the  curved  limb,  using  the 
inner  faces  of  the  thigh  and  ankle  as  points  for  counter-pressure.  Two 


"Figure  2354.     The  Boston  Chil- 
dren's Hospital  Bow-Leg 
Brace. 


Figure  2355.    Thomas'  Bow- 
Leg  Brace. 


Figure  3356. 


Bruce's  Bow-Leg 
Brace. 


forms  of  braces  are  in  use,   bars  of  rigid  steel  with  elastic  pressure,  and 
bows  of  spring  steel  exerting  direct  pressure. 


BOW- LEGS.  989 

Braces  in  which  upright  bars  are  used  as  a  base  from  which  to  exert 
elastic  or  bandage  tension,  may  be  constructed  in  a  similar  manner  to  those 
employed  in  cases  of  paralysis.  While  they  may  be  manufactured  with  a 
single  inside  bar  or  with  double  bars,  the  latter  only  should  be  employed. 
This'  is  advised  not  because  a  single  upright  lacks  sufficient  strength  to  act 
as  a  support  for  lateral  traction,  but  because  such  braces  have  a  tendency  to, 
and  in  most  cases,  rotate  more  or  less  around  the  limb  to  which  they  are 
applied.  This  disposition  to  "crawl"  not  only  renders  traction  uncertain, 
but  when  flexed,  the  degree  of  tension  changes  with  the  aspect  of  the  limb. 

It  is  advisable  in  only  a  few  cases  to  construct  braces  that  do  not  extend 
above  the  knee.  The  majority  of  cases,  even  where  the  deformity  is  not 
seen  to  include  the  knee-joint  or  femur,  will  make  more  rapid  and  satis- 
factory progress  when  the  braces  are  extended  to  include  the  thigh.  Trac- 
ings of  the  curved  limb  before  beginning  treatment  should  be  made  and 
preserved  in  all  cases.  Braces  of  this  type  may  be  made  with  or  without  a 
knee-joint,  but  when  they  include  the  foot,  they  should  be  constructed  with 
a  joint  at  the  ankle. 

The  Boston  Children's  Hospital  Bow-Leg  Brace,  as  may  be  seen  by  con- 
sulting figure  2354,  consists  of  a  single  rigid  upright  withoiit  a  knee-joint, 
extending  from  the  sole  of  the  foot  to,  and  partly  encircling,  each  thigh. 
It  should  pass  just  below  the  adductor  muscles  to  avoid  irritating  these 
parts  when  walking.  The  upper  rear  extremity  should  rest  on  the  post- 
trochanteric  sulcus.  This  brace  may  be  curved  so  as  to  evert  the  feet  by 
changing  the  curve  of  the  arms  which  may  be  united  and  drawn  together 
by  a  rear  strap.  Sole  leather  pads  attached  to  the  uprights  by  straps  and 
buckles  rest  on  the  points  of  extreme  convexity.  These  bands  may  be  of 
strong  elastic,  although  a  firm  leather  strap  will  answer  every  indication. 
In  severe  cases,  particularly  in  children  passing  the  eburnating  period,  it 
is  advisable  to  construct  the  brace  with  a  steel  inner  thigh-pad  attached  to 
the  top  portion  of  the  upright  just  where  it  is  curved  to  pass  anterior  to  the 
thigh. 

Thomas'  Bow-Leg  Brace,  as  it  appears  in  figure  2355,  is  made  of  soft 
iron,  the  main  side-bar  extending  from  the  upper  margin  of  the  tibia  to  the 
sole  of  the  foot.  At  the  upper  end  is  attached  a  band  which  passes  about 
two-thirds  around  the  leg.  The  lower  end  is  forged  round,  bent  at  a  right 
angle  and  inserted  into  a  hole  in  the  side  of  the  heel  of  the  shoe.  The  cor- 
rective force  is  exerted  by  means  of  a  broad  strap  as  shown  in  the  illustra- 
tion. 

As  generally  applied,  the  bandages  necessary  to  secure  proper  corrective 
force,  interfere  with  circulation  and  prevent  healthy  development.  This 
brace  is  therefore  little  used  excepting  in  dispensary  or  charity  cases  where 
cheapness  is  the  principal  recommendation. 

Bruce' s  Bow-Leg  Brace,  as  displayed  in  figure  2356,  consists  of  three 
pieces,  with  joints  corresponding  to  the  ankle  and  knee,  and  is  placed  upon 
the  inner  aspect  of  the  limb.  The  first  segment  of  the  instrument  extends 
from  the  sole  it  the  shoe  to  the  ankle-joint,  and  is  riveted  directly  to  the 
shoe  in  front  of  the  heel.  The  second  is  a  narrow  strip  of  stiff  steel  having 
a  curvature  in  a  direction  opposite  to  the  deformity.  The  third  extends  a 
short  distance  above  the  knee-joint,  and  is  provided  with  a  curved  piece 
riveted  at  right  angles  to  the  shaft  of  the  instrument.  A  roller  bandage 
is  carried  around  the  leg  and  over  the  instrument,  the  latter  being  drawn 
up  close  to  the  limb,  as  shown  in  the  illustration.  The  curved  shaft  being 
made  of  spring-steel,  and  tempered,  when  straightened  and  drawn  close  to 


990 


ORTHOPEDIC    SURGERY. 


the  limb,  gently  tends  to  return  to  its  former  curve.  The  pads  attached  to 
the  instrument  opposite  the  ankle-  and  knee-joints,  serve  as  points  of 
counterpressure. 

This  brace  is  to  be  worn  day  and  night,  and  should  be  removed  each  day 
in  order  to  manipulate  the  muscles,  as  the  prolonged  wearing  of  bandages, 
even  though  the  patient  exercises  considerably,  is  likely  to  cau*  2  more  or 
less  muscular  atrophy. 

This  brace,  though  advised  by  many  writers,  'seems  more  objectionable 
than  the  pattern  previously  described.  Healthy  development  can  hardly 
proceed  under  the  pressure  of  such  a  system  of  bandages  as  is  necessitated 
in  the  use  of  this  appliance, 


Figure  2357.    Plain  Double 
Bar  Bow-Leg  Brace. 


Figure  2358.     Short  Single  Bar 
Bow-Leg  Brace. 


Figure  2359.     Long  Single  Bar 
Bow-Leg  Brace. 


The  Bow-Leg  Brace,  shown  by  figure  2357,  exhibits  the  ordinary  pattern 
as  usually  advised  by  instrument  makers.  It  consists  of  a  double  bar  with 
a  stirrup  and  joint  at  the  knee.  Two  posterior  semi-circular  bands  connect 
the  uprights,  one  at  the  thigh,  the  other  just  below  the  knee.  These  are 
padded,  the  leather  continuing  around  the  limb  where  the  two  ends  are 
united  with  a  strap  and  buckle.  A  compression  pad  is  placed  opposite  the 
point  of  greatest  convexity.  This  may  be  attached  to  the  upright  by 
leather  elastic  or  cloth  straps. 

Figure  2359  shows  the  same  design  with  a  single  bar,  while  figure  2358 
exhibits  one  with  a  single  bar  extending  only  to  the  knee.  These  three 
patterns  are  all  inferior  to  those  previously  described. 


ANTERIOR  BOW-LEGS. 


Anterior  curvature  of  the  tibia,  after  children  have  passed  the  age  of 
eburnation,  is  seldom  relieved  by  any  but  operative  measures.  Osteoclasis 
in  young  patients  answers  a  good  purpose,  provided  the  point  of  curvature 
is  not  too  near  a  joint.  When  this  condition  exists  or  when  the  bones  are 
hard  and  firm,  osteotomy  alone  is  available. 


WEAK    ANKLES. 


991 


The  Anterior  Curvature  Brace  for  deflection  of  the  tibia,  as  represented 
in  figure  2360,  comprises  a  double-bar  leg-brace  with  stirrup  and  strong  calf- 
band.  Two  methods  are  employed  for  correcting  the  deformity :  The  first 


\ 


Figure  2360.    Brace  for  Anterior  Curvature  of  the  Tibia. 


one  is  to  attach  a  strong  elastic  bandage  to  each  of  the  uprights  in  such  a 
manner  that  pressure  on  the  convexity  of  the  tibia  will  tend  to  straighten 
it.  This  may  be  accomplished  by  constructing  the  elastic  portion  in  two 
sections  and  uniting  them  by  a  lacer,  so  that  any  desired  degree  of  pressure 
may  be  obtained.  Either  in  addition  to  the  bandage  or  as  a  separate 
means,  corrective  force  may  be  procured  by  attaching  a  strong  curved  steel 
spring  to  the  calf-band  in  such  a  manner  that  its  convexity  shall  be  next  to 
the  limb.  The  spring  should  project  downward,  its  tip  being  opposite  the 
point  of  greatest  curvature.  By  passing  a  strong  leather  band  around  the 
limb  and  fastening  its  tips  to  the  lower  end  of  the  spring,  any  desired 
pressure  may  be  secured. 


WEAK  ANKLES. 

This  affection  in  many  cases,  unless  corrected,  will  result  in  the  condi- 
tion known  as  flat-foot.  So  great  is  the  tendency  toward  the  latter,  that 
many  good  surgeons  apply  an  apparatus  that  not  only  acts  as  a  lateral  brace 


Figure  2361.    Weak- Ankle  Brace. 

to  the  weak  joint  but  also  supports  the  arch  of  the  foot.  Pronounced  cases 
are  usually  treated  the  same  as  talipes  valgus,  as  the  deformity  is  in  reality 
a  mild  form  of  this  complication. 


992  ORTHOPEDIC    SURGERY. 

The  Plain  Weak- Ankle  Brace,  as  exhibited  in  figure  2361,  is  applicable 
only  in  cases  of  a  mild  type,  usually  those  resulting  from  injury  It  con- 
sists of  two  upright  bars  united  at  their  lower  extremities  by  a  stirrup  pass- 
ing beneath  and  fastened  to  the  shoe,  while  the  upper  ends  are  attached  to 
a  semi-circular  calf-band  that  passes  posteriorly  around  the  Ijmb.  A  cir- 
cular pad  should  be  placed  on  the  inner  side  of  the  brace-joint  toward 
which  the  ankle  turns.  This  should  be  soft  and  elastic  and  so  placed  as  to 
prevent  the  ankle  from  assuming  an  abnormal  position. 


CLUB-FOOT. 

The  treatment  of  this  class  of  deformities  is  directed  toward  returning 
the  displaced  parts  to  their  normal  positions  and  retaining  them  until  there 
is  no  longer  a  disposition  to  distortion.  The  corrective  measures  may  be 
either  mechanical  or  operative,  the  latter  usually  followed  by  the  use  of  a 
retention  apparatus.  It  is  sought  either  to  correct  the  distortion  by  the 
aid  of  mechanical  appliances  or  to  retain  normal  relations  after  they  have 
been  secured  by  radical  methods.  With  the  exception  of  forcible  correction, 
no  instruments  are  required  in  the  radical  procedures  excepting  such  as  are 
described  under  the  chapters  on  Minor  Operative,  and  Bone  and  Joint 
Surgery. 

Operative  Treatment,  so  far  as  it  relates  to  incisions,  resections,  osteot- 
omy, etc.,  requires  only  such  instruments  as  have  been  already  described 
under  Minor,  and  Bone  and  Joint  Surgery.  When  immediate  correction  or 
extreme  force  must  be  applied,  powerful  clamps,  wrenches  or  osteoclasts  are 
frequently  necessary.  They  are  employed  to  stretch  or  rupture  contracted 
ligaments. 


Figure  23G2.    Bradford's  and  Lovett's  Lever  Corrective  Apparatus. 

Bradford's  and  Lovett's  Corrective  Apparatus,  as  traced  in  figure  2362, 
consists  of  a  steel  bar  applied  to  the  inner  aspect  of  the  sole  of  the  foot  and 
long  enough  to  furnish  ample  leverage  for  correction.  A  semi-circular  arm 
of  steel  is  attached  to  this  bar  by  a  collar  and  screw  which,  as  it  passes 
under  the  foot,  is  so  arranged  as  to  secure  a  firm  contact  on  the  outer  and 
upper  side  of  the  astragalus.  The  front  of  the  foot  rests  on  the  sole-plate. 
This  extends  to  the  posterior  margin  of  the  cuboid,  but  should  not  reach  as 
far  as  the  os  calcis.  This  plate,  with  an  upper  arm,  may  be  moved  along 
the  bar  to  any  desired  point. 

If  the  screws  are  all  tightened,  the  foot  is  not  only  held,  but  may  be 
flexed  or  curved  to  any  desired  extent. 

Mechanical  Means  may  be  the  use  of  bandages,  metal  or  similar  splints, 
or  elastic  pressure  by  straps,  artificial  muscles,  etc.  These  may  be  em- 
ployed singly  or  in  any  combination. 


CLUB-FOOT. 


993 


The  use  of  bandages  requires  no  special  apparatus  unless  it  he  some 
means  for  holding  the  foot  in  proper  shape  during  the  hardening  of  a  plaster 
of  paris  bandage. 


Figure  2363.    Sherman's  Foot  Holder. 

Sherman's  Foot  Holder,  the  construction  of  which  is  explained  by  figure 
2363,  is  colloquially  called  by  its  author  a"  cribbage  board. "  It  is  employed 
to  hold  a  foot  in  the  correct  position  following  operative  procedures,  while 
the  plaster  of  paris  splint  hardens.  The  apparatus  consists  of  a  hardwood 
plank  27  inches  long,  12  inches  wide  and  iy2  inches  thick.  The  plank  is 
pierced  with  holes  i  inch  in  diameter,  regularly  distributed  about  i  y2  or  2 
inches  apart.  Four  or  six  pegs,  each  about  6  inches  in  length,  are  pro- 
vided, each  accurately  turned  so  that  their  lower  ends  closely  fit  the  holes 
in  the  boards,  while  the  upper  ends  are  slotted  to  serve  as  posts  for  holding 
the  loose  ends  of  the  bandages.  After  the  plaster  of  paris  splint  has  been 


Figure  2364.    Taylor's  Club-Foot  Brace. 


Figure  2365.    Ridlon's  Club-Foot  Shoe. 


applied  and  while  it  is  still  soft,  the  foot  with  toes  up  may  be  placed  in  the 
center  of  the  board,  the  long  diameter  of  the  latter  being  in  line  with  the 
long  axis  of  the  limb.  With  ordinary  muslin  bandages  properly  attached 
to  the  foot  and  secured  to  the  peg,  the  latter  may  be  employed  to  tighten 
the  bandages  by  twisting,  and  the  foot  thus  everted,  abducted,  or  flexed  to 
any  desired  extent  and  held  in  this  position  until  the  plaster  has  hardened. 

Splints  composed  largely  of  metal  or  other  firm  material  are  more  com- 
monly applied  in  the  treatment  of  this  class  of  deformities  than  other  means. 
They  usually  consist  of  specially-constructed  shoes  or  of  firm  corrective 
braces  that  may  be  attached  to  ordinary  shoes. 

Taylor's  Club-Foot  Brace,  as  pictured  in  figure  2364,  consists  of  a  flat 
steel  sole-plate  closely  fitted  to  the  lower  surface  of  the  foot  and  extending 
forward  to  the  balls  of  the  toes.  The  inner  margin  of  this  plate  projects 


994 


ORTHOPEDIC    SURGERY. 


upward  in  the  form  of  a  wing  which,  when  closely  fastened  to  the  foot, 
holds  the  sole-plate  in  proper  position.  An  upright  shaft  joined  at  the 
ankle  is  firmly  attached  to  the  sole-plate.  This  extends  upward  as  far  as 
the  middle  of  the  calf,  where  it  is  attached  by  means  of  a  band  and  buckle. 
The  foot  is  secured  to  the  sole-plate  by  straps  of  webbing  tightly  buckled 
after  the  manner  shown  in  the  illustration.  The  apparatus  acts  by  the 
leverage  of  the  upright,  which  seeks  to  force  the  foot  into  a  correct  posi- 
tion. If  required,  heel-straps  may  be  used  to  restrain  the  ankle,  and  when 
necessary,  the  whole  may  be  aided  by  adhesive  plaster.  It  is  light  in  con- 
struction and  can  be  worn  inside  a  large-sized  shoe  without  interfering  with 
locomotion.  The  apparatus  may  be  used  as  a  walking  retention  splint  fol- 
lowing operative  measures. 

The  Ridlon  Club-Foot  Brace,  as  traced  in  figure  2365,  is  strictly  a  reten- 
tion apparatus,  and  is  not  used  as  a  corrective  force.  It  is  applied  after  the 
deformity  has  been  overcome  by  other  means.  It  consists  of  a  foot-plate 
made  to  accurately  fit  the  contour  of  the  sole  and  against  which  the  foot  is 
held  by  straps  and  a  shoe.  A  side-bar  extending  to  the  garter  line  below  the 
knee,  controls  the  lateral  motion  by  leverage.  This  is  joined  to  the  foot- 
plate by  a  rivet,  and  when  necessary,  provided  with  a  stop-joint  to  limit  an- 
tero-posterior  motion  in  either  direction  to  any  desired  degree.  In  construct- 
ing this  brace,  it  is  necessary  to  have  a  plaster  mold  of  the  patient's  foot 
made  while  the  latter  is  in  as  nearly  a  correct  position  as  possible. 


Figure  2366.    Sayre's  Im-  Figure  2367.    Shafer's  Club-Foot  Shoe, 

proved  Ball  and  Socket 
Club-Foot  Shoe. 

Sayre's  Improved  Ball  and  Socket  Club-Foot  Shoe,  as  illustrated  in 
figure  2366,  is  constructed  after  the  pattern  of  Scarpa,  with  the  sole-plate 
in  two  sections,  united  by  a  ball  and  socket  joint.  The  heel-piece  is  in  the 
form  of  a  metallic  cup,  padded  and  covered  with  leather.  The  latter  is 
carried  over  the  instep  and  ankle  and  fastened  by  lacing.  An  upright 
extension  of  the  sole-plate  presses  laterally  against  the  base  of  the  first 
metatarsal  bone.  Two  uprights  with  stirrup  and  calf-band  jointed  at  the 
ankle,  provide  for  lateral  chains,  and  springs  connect  the  calf-band  or 
upper  portion  of  the  uprights  with  the  sole-plate  opposite  the  toes.  This 
ensures  tension,  if  there  be  a  tendency  toward  talipes  equinus.  The  lateral 
external  coiled  spring,  or  rubber  cord  attached  to  the  toe-plate  and  the 
upright  below  the  joint  may  produce  shortening  on  the  side  of  the  shoe 
upon  which  it  is  placed.  As  the  sole-joint  is  universal,  this  spring  may  be 


CLUB-FOOT. 


995 


placed  upon  the  outer  or  inner  side,  depending  upon  whether  the  case  is  one 
of  valgus  or  varus.  The  upper  leather  which  forms  the  shoe,  is  laced 
because  it  can  be  more  perfectly  adjusted  than  with  straps  and  buckles. 

Shafer's  Club-Foot  Shoe,  as  shown  in  figure  2367,  is  particularly  adapted 
for  stretching  the  plantar  fascia  in  cases  of  talipes  equinus.  It  consists  of 
a  shoe  with  a  sole-plate  in  two  parts,  the  whole  attached  to  upright  bars  by 
means  of  a  rack  and  pinion  or  endless  screw.  The  apparatus  is  applied  to 
the  foot  in  its  deformed  position,  and  a  firm  retention  strap  is  carried  over 
the  head  of  the  astragalus,  while  a  second  strap  extends  from  behind  the 
heel  to  the  front  of  the  shoe.  By  means  of  a  rack  and  pinion  under  the 
shoe,  the  foot-piece  may  be  forced  forward  and  the  heel  drawn  downward. 
By  means  of  the  endless  screw  the  action  of  the  tendo  Achillis  and  plantar 
fascia  may  be  counteracted  and  the  foot  flexed  in  normal  position. 

Stillman's  Night  Brace,  as  represented  in  figure  2368,  for  cases  of  club- 
foot,  is  intended  particularly  for  the  correction  of  talipes  equinus.  As 
usually  constructed,  it  may  be  attached  to  an  ordinary  slipper.  It  consists 
of  a  thin  plate  of  metal  attached  to  the  sole  of  the  shoe  and  riveted  to  the 
stirrup.  The  latter  terminates  in  two  upright  lateral  bars,  hinged  at  the 
ankle,  and  provided  with  calf-  and  ankle-bands,  as  shown  in  the  illustration. 
A  detachable  hoop  joins  the  two  uprights  just  below  the  calf-band,  passing 
anteriorly  around  the  limb.  A  second  hoop  passes  over  the  foot  opposite 


Figure  2368.    Stillman's  Night  Brace 
for  Club-Foot. 


Figure  i 


i9.    Bradford's  and  Lovett's  Walking 
Appliance  for  Club-Foot. 


the  toes,  where  it  is  attached  to  a  sole-plate.  These  hoops  or  stirrups  are 
connected  by  elastic  webbing.  The  latter  is  supplied  with  buckles,  so  that 
any  degree  of  traction  may  be  obtained. 

Bradford's  and  Lovett's  Appliance  for  Club-Foot  is  intended  for  use,  fol- 
lowing correction,  in  order  that  the  tarsal  bones  may  be  retained  in  proper 
position  until  the  muscles  and  ligaments  have  adapted  themselves  to  their 
normal  but  new  position.  As  shown  in  figure  2369,  the  apparatus  consists 
of  a  leg-brace,  extending  from  the  iliac  crests  to  the  sole  of  the  foot.  It  is 
provided  with  hip-,  knee-  and  ankle-joints  and  with  calf-,  thigh-  and  waist- 


996 


ORTHOPEDIC    SURGERY. 


bands.  If  there  be  a  tendency  to  rotation  of  the  limb,  perineal  straps 
should  be  added  to  the  iliac  band.  This  appliance  will  effectually  prevent 
inversion  and  will  assist  in  securing  normal  conditions  without  incurring 
the  danger  of  a  return  of  the  displacement. 


FLAT-FOOT. 


The  correction  of  flat-foot  may  be  best  accomplished  by  a  thin  metallic 
sole,  to  be  worn  inside  the  shoe.  Many  forms  of  pads  have  been  advised, 
but  with  the  exception  of  those  manufactured  of  soft  rubber  in  a  succes- 
sion of  sizes,  none  have  proved  beneficial. 


Figure  8370.    Plain  Sole  for  Fiat-Foot. 

The  Plain  Sole  for  Fiat-Foot,  as  pictured  in  figure  2370,  consists  of  an 
unyielding  steel  plate,  formed  over  a  metallic  mold  of  the  affected  foot. 
In  making  a  cast  from  which  to  secure  a  mold,  the  foot  should  first  be 
placed  in  a  normal  position.  This  apparatus  allows  the  foot  to  rest  upon 
its  natural  supports,  the  heel  and  ball  of  the  foot.  It  does  not  in  any  way 
restrict  normal  motion  and  activity,  but  provides  support  to  the  weakened 
muscles  and  ligaments.  It  is  usually  comfortable,  and  the  painful  pressure 
on  the  sole  of  the  foot,  often  complained  of  when  other  forms  of  appliances 
are  used,  is  avoided. 


Figure  2372.    Soft  Rubber  Pads  for  Correcting  Flat- Foot. 

Soft  Rubber  Pads,  for  the  correction  of  flat-foot,  are  portrayed  in  figure 
2372,  showing  them  in  horizontal  and  vertical  sections.  They  are  in- 
tended for  attachment  to  the  upper  surface  of  the  shoe-sole  by  nails  or 
rivets.  Generally  one  of  the  smaller  sizes  is  first  attached,  and  this  is 
afterward  replaced  by  the  larger  sizes  in  succession  until  the  foot  has  been 
returned  to  its  normal  position.  As  they  are  elastic,  they  furnish  a  comfort- 
able as  well  as  an  efficient  apparatus. 


PES    CAVUS TALIPES    CAVUS. 


997 


PES  CAVUS— TALIPES  CAVUS. 

This,  when  not  too  pronounced,  may  be  benefited  by  the  use  of  soles  of 
proper  shape,  and  in  some  cases  by  immediate  corrective  apparatus. 

Bigg's  Apparatus  for  Pes  Cavus,  as  shown  by  figure  2371,  consists  of  a 
curved  steel  plate,  provided  with  means  by  which,  after  it  has  been  firmly 


Figure  2371.    Bigg's  Apparatus  for  Pes  Cavus. 

attached  to  the  foot,  it  may  be  gradually  changed  to  the  normal  position  by 
means  of  a  rack  and  pinion.  A  metallic  cup  or  heel  extension  forms  a 
socket  in  which  the  heel  of  the  foot  may  be  firmly  secured  by  means  of  a 
strap  and  buckle.  A  similar  broad  band  extends  across  the  center  of  the 
foot,  while  a  third  one,  passing  across  the  bases  of  the  toes,  holds  the 
anterior  portion  of  the  foot  in  close  contact  with  the  plate.  With  the  foot 
thus  secured,  any  desired  amount  of  corrective  force  may  be  obtained. 


EXTENSION  APPARATUS  FOR  THE  LEG. 

Extension  for  shortening  limbs  may  be  procured  in  forms  varying  from 
the  ordinary  thickened  soles,  constructed  by  shoe-makers,  to  the  deceptive, 
yet  comfortable  apparatus  outlined  in  figure  2375. 


Figure  2373.    Ordinary  Leg  Extension.  Figure  2374.    Steel  Leg  Extension. 

The  Plain  Leg  Extension,  illustrated  in  figure  2373,  represents  the 
ordinary  form  of  apparatus  as  constructed  by  shoe-makers  generally.  It 
may  be  made  from  wood,  cork,  or  leather,  the  latter  being  objectionable 
on  account  of  its  weight.  Wood,  if  protected  by  a  steel  sole,  is  probably 


998 


ORTHOPEDIC    SURGERY. 


the  best  material,  particularly  if  the  case  requires  a  sole  of  considerable 
thickness. 

The  Steel  Extension,  traced  in  figure  2374,  may  be  constructed  with  a 
solid  or  fenestrated  sole,  and  may  be  with  or  without  the  central  post  shown 
in  the  illustration. 


Figure  2375.    Improved  Extension  for  Shortened  Legs. 

The  Improved  Extension  for  Shortened  Legs,  as  represented  in  figures 
2375  and  2376,  presents  advantages  not  found  in  any  other  form  of  appli- 
ance with  which  we  are  familiar.  It  consists  of  a  wooden  extension 
accurately  fitted  to  the  sole  of  the  foot,  while  the  latter  is  in  a  state  of  com- 
plete extension.  Usually  it  is  manufactured  with  a  jointed  toe-piece,  after 
the  manner  of  artificial  limbs.  Well -seasoned  English  willow  is  the  mate- 


Figure  2376.    Improved  Extension  for  Shortened  Legs  as  It  Appears  in  Service. 


rial  generally  employed,  the  whole  being  covered  with  raw-hide.  As  repre- 
sented in  the  illustration,  a  leather  cover  in  the  form  of  an  extension  or 
shoe-upper  encompasses  the  artificial  portion  and  patient's  foot.  This  is 
provided  with  lacings  like  those  in  an  ordinary  shoe. 

In  many  cases  of  this  character  the  tendo  Achillis  is  frequently  con- 
tracted, the  foot  in  such  instances  naturally  assuming  the  shape  required 
for  the  successful  application  of  this  instrument.  Without  contraction, 
however,  the  foot  soon  becomes  accustomed  to  what  at  first  would  seem  an 
awkward  and  uncomfortable  position.  Whether  for  a  lady  or  gentleman, 
the  apparatus  presents  a  far  more  sightly  appearance  than  any  other  form 
of  apparatus.  Furthermore,  it  is  more  durable  and  is  cleanly. 


CHAPTER  XXXVIII. 


PROSTHETIC    SURGERY. 

Prosthesis,  while  technically  embracing  all  substitutes  for  bodily 
defects,  will  be  confined  in  this  chapter  to  its  relation  with  artificial  limbs 
following  amputations.  This  subject  is  introduced  here  with  a  view  of 
presenting  such  mechanical  principles  as  are  necessarily  employed  in  the 
construction  of  artificial  limbs,  and  of  suggesting  to  the  surgeon  the  method 
and  technique  that  will  afford  to  the  patient  the  greatest  possible  advan- 
tages in  securing  a  serviceable  and  properly-fitting  substitute. 

Within  a  comparatively  short  time,  prosthetic  science  has  advanced  to 
that  state  of  perfection  where,  with  but  few  exceptions,  when  a  patient  is 
referred  to  as  a  cripple  as  the  result  of  amputation  of  one  or  both  of  the 
lower  extremities,  it  is  because  the  surgeon  has  operated  in  an  imperfect 
manner,  or  the  patient  has  secured  the  services  of  an  unskilled  prostheti- 
cian.  It  is  not  many  years  since  anyone  who  had  been  so  unfortunate  as 
to  lose  even  a  single  limb  was  considered  wholly  or  partially  disabled — a 
cripple  for  life.  To-day  there  are  thousands  of  men,  women  and  children 
who,  although  they  have  suffered  amputation  of  one  or  both  of  their  lower 
limbs,  are  enabled,  by  means  of  artificial  appliances,  to  walk  our  streets  and 
attend  to  their  various  duties  and  vocations,  moving  with  such  an  easy  and 
graceful  step  that  they  would  consider  it  an  insult  to  be  referred  to  as  crip- 
ples. The  science  of  prosthesis,  within  the  last  decade,  has  made  rapid 
strides,  until,  to-day,  it  is  following  closely  behind  an  advanced  system  of 
humane  surgery.  The  surgeon  each  year  is  becoming  better  acquainted 
with  the  principles  essential  to  the  construction  of  artificial  limbs,  and,  as  a 
result,  he  is  adopting  a  better  technique  and  more  suitable  points  for 
amputations. 

For  ages  it  was  the  custom  for  the  surgeon  to  amputate  without  regard 
for  the  prosthetic  principles  involved,  seeming  to  believe  that  if  he  saved 
every  ounce  of  tissue  and  every  fraction  of  an  inch  of  bone  consistent  with 
the  safety  of  the  life  of  his  patient,  he  had  fulfilled  the  requirements  of 
the  highest  demands  of  his  profession.  The  artificial  limb  maker,  while 
frequently  brought  into  contact  with  cases  presenting  diseased,  sensitive 
or  ill-shaped  stumps,  while  he  might  secretly  sympathize  with  the  unfor- 
tunate patient  and  regret  that  he  had  fallen  into  such  unskilled  surgical 
hands,  seldom  dared  to  enter  a  protest  against  methods  that  for  ages 
entailed  much  suffering  on  the  part  of  patients,  and  unnecessarily  a  large 
percentage  of  cripples. 

Gross,  one  of  the  greatest  surgical  mechanics  the  world  has  ever  known, 
said,  more  than  a  quarter  of  a  century  ago,  in  his  "System  of  Surgery": 
"There  is  reason  to  believe  that  the  inconveniences  and  suffering  occa- 
sioned by  the  use  of  artificial  limbs  are  more  frequently  attributable  to  the 
misconduct  of  the  surgeon  than  to  the  want  of  skill  on  the  part  of  the 
manufacturer  of  the  substitute." 

The  "golden  rule"  usually  practiced  in  amputations  has  been  to  save 

999 


1000  PROSTHETIC    SURGERY. 

everything  possible,  and  to  appreciate  how  rig-idly  this  has  been  adhered 
to,  one  has  but  to  examine  into  the  various,  yet  similar  tarsal  operations, 
no  one  of  which  possesses  much  advantage  over  others  of  like  character, 
yet  each  bears  the  name  of  the  surgeon  who  gave  it  prominence  or  birth. 

Patients  wearing  artificial  legs  may  be  divided  into  two  classes,  those 
who  appear  to  be  and  who  are  cripples,  and  those  who  would  feel  insulted 
if  they  were  referred  to  as  such.  Among  prostheticians  the  former  would 
be  called  "unfavorable"  and  the  latter  "favorable"  cases,  and  in  considering 
this  subject  we  shall  aim  to  present  such  facts  and  principles  as  will  enable 
the  surgeon  to  decrease  the  proportion  of  the  former,  and  correspondingly 
increase  that  of  the  latter.  The  old  "golden  rule,"  still  advocated  in 
nearly  all  our  standard  text-books  and  taught  in  our  colleges,  sets  forth  as 
an  inflexible  principle  that  in  amputations  it  is  the  duty  of  the  surgeon  to 
save  every  ounce  of  tissue  and  every  fraction  of  an  inch  of  bone.  This 
rule  teaches  that  the  value  of  the  stump  in  all  cases  increases  with  its 
length,  and  in  many  text-books  it  is  asserted  that  stumps  must  admit  of 
pressure  on  the  end  of  the  bone. 

While  a  strict  adherence  to  these  rules  will  seldom  lead  the  surgeon 
astray,  we  will  endeavor  to  show  that,  in  certain  instances  and  under  some 
conditions,  the  value  of  the  stump  does  not  increase  with,  its  length,  and 
that  it  is  not  necessary,  although  preferable,  that  the  weight  of  the  patient 
be  all,  or  even  in  part,  carried  on  the  end  of  the  stump.  A  greater  danger, 
however,  than  selecting  a  bad  point  for  an  amputation  besets  the  patient  if 
the  surgeon  has  failed  to  acquaint  himself  with  the  relations  that  must 
exist  between  the  stump  and  the  appliance  to  be  worn  upon  it.  Perfect 
results  can  be  secured  only  when  the  surgeon  realizes  that,  after  selecting 
the  most  favorable  point  for  an  amputation,  each  step  in  the  technique 
adopted  must  be  chosen  with  a  special  view  of  its  best  serving  the  interests 
of  the  patient  in  the  adjustment  of  an  artificial  limb. 

It  must  be  admitted  that,  while  it  is  a  fearful  condition  that  necessitates 
the  loss  of  a  limb,  it  is  still  more  fearful  to  be  left  a  cripple  because  of  a 
lack  of  proper  understanding  on  the  part  of  the  surgeon.  The  surgeon 
should  know  how  and  where  as  well  as  when  to  amputate,  so  that  if  the 
patient  survive  the  original  condition  necessitating  amputation,  he  may  be 
given  every  opportunity  to  secure  an  appliance  that  will  to  some  extent 
compensate  for  the  loss  of  the  natural  part. 

Union  by  first  intention,  a  cicatrix  so  smooth  and  perfect  as  to  be 
scarcely  noticeable  and  a  beautifully  shaped  stump-ending  may  yet  leave 
the  patient  in  such  condition  that  an  artificial  substitute  can  be  worn 
only  with  pain  and  discomfort. 

The  increased  number  of  maimed  patients  incident  to  the  War  of  the 
Rebellion,  the  large  quantity  of  heavy  machinery  used  in  modern  times, 
and  the  rapidity  with  which  much  of  it  is  moved  and  operated,  have  largely 
increased  the  number  of  patients  who  yearly  apply  for  artificial  limbs. 
This  has  resulted  in  a  general  activity  among  manufacturers,  a  readjust- 
ment of  former  methods  and  an  improved  construction  that  has  placed 
the  products  of  American  manufacturers  far  in  advance  of  those  in  any 
other  portion  of  the  world. 

The  Requirements  of  a  Good  Stump  are  :  Proper  protection  for  the  end 
of  the  bone,  with  a  non-adherent,  integumentary  flap,  in  which  the  cicatrix 
is  located  to  one  side  of  the  bone-ending ;  sufficient  length  to  provide  lever- 
age with  which  to  swing  an  artificial  limb,  and  freedom  from  encicatrized 
nerve-endings.  These  principles  are  of  vital  importance,  and  a  lack  of  the 


PROSPHETIC    SURGERY.  1001 

proper  understanding  of  them  has  caused  many  an  otherwise  brilliant  sur- 
geon to  leave  an  occasional  patient  unnecessarily  crippled. 

After  an  amputation  has  been  decided  upon,  whether  for  the  purpose  of 
protecting  life  from  impending  danger,  to  remove  a  cause  of  suffering  or 
to  relieve  a  source  of  inconvenience,  the  first  essential  is  to  select  that 
point  for  the  operation  which  will  afford  the  greatest  possible  use  of  the 
stump  to  the  patient.  In  performing  an  amputation  that  will  best  serve 
the  interests  of  the  patient  all  superfluous  and  useless  bone  and  tissue 
should  be  removed,  that  they  may  be  replaced  by  artificial  material  that  will 
be  of  service  and  value.  A  stump  that  will  admit  of  pressure  on  the  end 
of  the  bone  is  nearly  always  preferable,  provided  the  patient  secures  the 
services  of  an  expert  prosthetician.  This  principle  may  seem,  to  some 
extent,  at  variance  with  that  advocated  by  the  author  in  papers  published 
some  years  ago  ;  for  at  that  time  all  operations  in  and  about  the  ankle, 
tarsal  and  medio-tarsal  joints  were  discouraged  in  favor  of  amputations  at 
the  junction  of  the  lower  and  middle  thirds  of  the  tibia. 

This  position  was  taken  because  statistics  gathered  at  the  time  demon- 
strated beyond  doubt  that,  in  the  hands  of  the  ordinary  maker  of  artificial 
limbs,  under  the  then  existing  surgical  conditions,  a  large  percentage  of 
tarsal,  medio-tarsal  and  tibio-tarsal  amputations  resulted  in  crippled 
patients,  while  those  upon  whom  amputations  had  been  made  in  the  middle 
of  the  leg  fared  much  better  and  suffered  less,  with  a  decreased  risk  of 
re-amputation.  These  statistics  were  gathered  from  947  surgeons,  covering 
2793  amputations,  2135  of  which  were  amputations  at  or  near  the  junction 
of  the  lower  and  middle  thirds  of  the  tibia,  the  balance  having  been  made 
between  a  point  just  above  the  ankle-joint  and  the  metatarso-phalangeal 
articulation.  Of  the  tibial  amputations  90^  per  cent,  resulted  in  sound, 
healthy  stumps,  while  3^  per  cent,  required  re-amputation.  In  this  class, 
962  patients  were  seen  by  the  surgeon  after  they  were  wearing  or  had 
attempted  to  wear  an  artificial  limb,  86^  per  cent,  of  whom  walked  with 
an  easy  movement  and  a  comparatively  graceful  step.  Of  the  tarsal  and 
tibio-tarsal  amputations  82^  per  cent,  resulted  in  sound,  healthy  stumps, 
while  8T\  per  cent,  underwent  re-amputations.  Of  this  class  169  patients 
were  seen  by  the  surgeons  after  attempting  the  use  of  compensatory  appli- 
ances, and  only  54^5  per  cent,  were  found  to  walk  well.  How  many  of 
these  latter  cases  were  crippled  by  incompetent  and  unskillful  artificial 
limb  makers  can  only  be  conjectured. 

That  it  requires  greater  skill  to  fit  an  appliance  to  amputations  in  the 
foot  and  ankle-joint  is  unquestionable.  The  conditions  reported  as  exist- 
ing at  that  time,  and  the  statement  of  many  patients  who  had  suffered  re-am- 
putations because  of  operations  at  the  lower  points,  justified  the  abandon- 
ment at  that  time  of  many  procedures  which  up  to  that  time  had  been  looked 
upon  with  favor. 

The  articles  referred  to  were  followed  by  papers  from  others  who  had 
given  the  subject  attention,  prominent  among  whom  was  Marks,  of  New 
York,  who,  in  a  series  of  articles  attempted  to  demonstrate  that  end-bear- 
ing stumps,  or  those  that  would  admit  of  pressure  on  the  end  of  the  bone, 
were  preferable  in  all  cases.  While  we  are  not  prepared  to  accept  this  as 
an  inflexible  rule,  the  opinions  of  Marks,  owing  to  his  large  experience 
and  years  of  careful  study,  are  entitled  to  high  consideration. 

The  surgeon  should  bear  in  mind  that  artificial  limbs  have  members  and 
joints  corresponding  as  closely  as  may  be  in  length,  form  and  motion  to  the 
natural  ones,  and  that  as  the  latter  can  be  operated  only  by  means  of 


LLlElilE   LMr    USTI 


1002  PROSTHETIC  SURGERY. 

certain  necessary  anatomical  mechanism,  interference  with  which  impairs 
or  wholly  destroys  its  value,  so  the  artificial  substitute  must  depend  upon 
its  mechanism  if  it  is  to  successfully  fulfill  the  demands  made  upon  it. 

The  action  of  the  natural  leg,  while  being  used  for  locomotion,  is  largely 
automatic,  being  operated  principally  by  the  muscles  of  the  pelvis,  directed 
by  what  may  be  termed  muscular  sense ;  the  muscles  of  the  leg  and  foot 
being  mostly  employed  for  special  uses  and  as  stays  or  supports  to  keep 
the  leg  steady. 

In  the  simple  act  of  walking,  there  is  little  force  generated  other  than  in 
such  muscles  of  the  pelvis  as  have  their  insertion  in  the  upper  portion  of 
the  thigh ;  consequently,  in  the  construction  of  artificial  limbs,  makers  have 
practically  only  the  automatic  or  mechanical  action  to  deal  with  and 
imitate. 

For  instance,  the  natural  knee-joint  is  not  only  monaxial,  but  is  auto- 
matically self-locking,  because  the  bearings  of  the  ends  of  the  bones  form- 
ing this  joint  are  posterior  to  a  line  drawn  perpendicularly  through  the 
shafts  of  the  tibia  and  femur.  The  consequence  of  this  is  that  the  weight 
of  the  body,  when  the  leg  is  fully  extended,  naturally  maintains  this  posi- 
tion, while  over-extension  is  prevented  by  the  tightening  of  the  lateral  and 
posterior  ligaments.  Flexion  of  the  femur  upon  the  body  and  flexion  of 
the  knee  are  produced  simultaneously.  Following  these  flexions,  the  foot, 
in  walking,  from  a  state  of  rest,  though  not  at  first  moving  with  the  same 
relative  rate  of  speed  as  the  upper  portion  of  the  tibia,  quickly  acquires  an 
accelerated  motion  and  gains  a  momentum  of  sufficient  velocity  to  carry  its 
limb  to  complete  extension  of  the  knee,  where,  as  before  stated,  it  becomes 
self-locking. 

These  movements  being  largely  of  an  automatic  nature,  prostheticians 
have  only  to  understand  them,  and  a  limb  can  be  made  that  will  have  prac- 
tically the  same  action  and  do  nearly  the  same  work.  This  automatic 
action  can  be  closely  imitated  in  the  leg  for  the  simple  reason  that,  except 
in  hip  amputations,  or  those  immediately  below  it,  the  muscles  of  the  pelvis 
and  thigh  are  left  intact  and  capable  of  performing  their  natural  functions. 

Artificial  limb  makers  have  taken  advantage  of  this  and  have  repro- 
duced, as  far  as  possible,  this  simple  automatic  action.  The  result  has 
been  that  thousands  of  people  wear  these  appliances,  and  mingle  in  society 
for  years  without  their  acquaintances  coming  to  a  full  knowledge  of  their 
maimed  condition. 

The  artificial  limb  is  swung  forward  by  the  action  of  the  muscles  of  the 
pelvis  and  thigh ;  the  knee  bends  automatically  as  it  raises ;  the  lower  leg 
moves  forward  until  it  locks,  while  the  foot  accommodates  itself  to  any 
inequalities  of  the  ground.  As  soon  as  the  body  passes  over  the  active 
limb  and  the  latter  begins  to  point  obliquely  backward,  the  slack  of  the 
false  tendo  Achillis  is  taken  up,  and  the  ankle  at  once  becomes  rigid,  caus- 
ing the  wearer  to  rise  on  the  ball  of  the  foot  and  assist  in  propelling  the 
body  forward. 

With  the  exception  of  partial  foot  amputations,  the  proper  construction 
of  an  artificial  leg  requires  the  use  of  some  form  of  knee-joint  mechanism, 
by  which  motion  at  that  point  is  secured. 

The  Knee-joint  Irons,  shown  by  figures  2377  and  2378,  represent  the 
forms  generally  in  use ;  the  first  is  employed  when  operations  are  above  the 
knee,  the  second  when  the  point  of  selection  is  through  or  below  the  joint. 
The  first  may  be  used  in  all  cases  where  the  amputation  does  not  approach 
nearer  than  about  i  inch  above  the  joint.  It  consists  of  a  shaft  rotating 

1 0    B  FJ  H  J  J 
•^  [/  /  f  '"i  r  ?  '/  f-f rz 


PROSTHETIC    SURGERY.  1003 

within  a  cylinder  and  of  such  construction  and  packing  that  it  will  withstand 
years  of  wear  without  becoming  loose  or  inducing  loose  motion.  The  second 
is  used  in  all  cases  where  the  amputation  is  in  or  below  the  knee  joint.  It 
consists  of  two  lateral  bars  with  joints  similar  to,  though  of  better  construc- 


Fig-ure  2377.    Knee-joint  Irons  for  Figure  2378.    Knee-joint  Irons  for  Am- 

Amputations  below  the  Knee.  putations  in  and  above  the  Knee. 

tion  than,  those  employed  in  the  manufacture  of  deformity  apparatus. 
Biggs,  of  England,  an  authority  on  this  subject,  has  estimated  the  wearing 
service  of  the  first  as  being  forty  times  greater  than  that  of  the  second 
pattern  illustrated.  The  latter,  when  compelled  to  carry  a  weight,  too 
often  become  loose  and  annoying,  not  only  requiring  greater  care  but 
involving  more  expense  for  repairs. 

Artificial  limbs  in  which  the  cylindrical  form  of  joint  is  used  are  not 
only  durable,  but  they  are  lighter  than  when  constructed  with  the  rule- 
joint.  The  limb  shown  in  figure  2380,  manufactured  from,  willow  with  the 
cylindrical  joint,  designed  for  an  amputation  of  the  femur,  and  capable  of 
sustaining  a  weight  of  from  200  to  400  pounds,  need  not  weigh  more  than 
from  four  to  five  pounds,  while  those  with  the  rule-joints,  exhibited  in 
figure  2379,  usually  weigh  about  one  pound  more. 

Stumps  may  be  Divided  into  Two  Classes,  end-bearing  and  non-end-bear- 
ing. The  first,  as  their  name  implies,  will  admit  of  pressure  on  the  end  of  the 
bone,  either  because  the  medullary  canal  has  not  been  opened,  or  if 
opened,  has  been  covered  by  an  osteoplastic  operation.  The  second  will, 
as  a  rule,  include  all  plain  amputations  in  the  continuity  of  the  long  bones, 
and  such  operations  in  and  about  the  joints  as  produce  adherent  cicatrices, 
and  those  that  are  sensitive  from  any  cause.  Amputations  in  the  con- 
tinuity of  the  limb,  and  osteoplastic  operations,  together  with  those  in  which 
the  amputation  is  so  near  the  joint  as  not  to  open  the  medullary  canal,  will, 
if  made  under  proper  conditions,  permit  pressure  sufficient  to  carry  the 
weight  of  the  body  in  full  or  in  part. 

Flaps  should  be  composed  of  none  but  sound  tissue,  ample  to  furnish  a 
complete  covering  for  the  end  of  the  bone  without  tension.  Re-amputations 
are  frequently  necessary  because  the  zeal  of  the  surgeon  in  his  efforts  to 
save  as  much  of  the  limb  as  possible  has  led  him  to  include  lacerated  or 
poorly-nourished  tissues  in  one  or  both  of  the  flaps.  As  Marks  has  well 
expressed  it,  "It  is  far  better  to  sacrifice  bone  than  to  sacrifice  flap." 

While  flaps  must  be  large  enough  to  cover  the  end  of  the  stump  and 
close  the  wound  without  tension,  they  must  possess  a  sufficient  degree  of 


1004  PROSTHETIC    SURGERY. 

firmness  to  bear  the  necessary  contact  with  the  socket  of  the  artificial  limb 
that  both  the  natural  and  artificial  parts  may  move  and  be  operated  as  one. 
A  loose,  flappy,  redundant  stump-ending  is  not  only  difficult  to  fit  into  an 
artificial  limb  socket,  but  after  the  limb  is  adjusted,  the  excessive  soft  tissue, 
acting"  as  an  elastic  cushion,  will  cause  the  patient  to  limp  when  walking,  if 
pain  is  not  produced.  In  the  adjustment  of  an  artificial  limb  it  is  necessary 
that  the  socket  be  brought  in  contact  with  none  but  firm  tissues,  for  other- 
wise the  amount  of  lost  motion  that  will  be  created  between  the  remaining 
bones  of  the  natural  leg  and  the  substitute  will  prevent  a  perfect  execution 
in  walking. 

In  Selecting  the  Point  for  an  Amputation,  the  question  of  how  and  where 
to  form  the  flaps  should  be  of  first  consideration.  Unless  the  bone  be 
properly  protected,  sloughing  will  be  likely  to  follow.  If  the  cicatrix  be 
drawn  tightly,  it  will  be  highly  sensitive,  and  if  it  pass  across  the  sawn  end 
of  the  bone,  there  is  danger  that  it  may  become  adherent  and  unfitted  for 
bearing  weight.  In  amputations  in  contiguity  to  the  knee,  this  is  most 
essential,  for  otherwise  the  instrument  maker  may  be  unable  to  adjust  an 
end-bearing  leg,  a  pattern  usually  preferable  to  those  in  which  the  weight 
is  carried  by  the  cone  shape  of  the  socket  and  the  ischio-perineal  region. 

As  the  pressure  necessary  in  swinging  an  artificial  limb  and  the  shock 
produced  by  sudden  jars  and  concussions  are  received  on  the  anterior  sur- 
face of  the  limb,  it  is  better  that  the  cicatrix  be  located  on  the  posterior 
aspect.  This  necessitates  a  long  anterior  flap. 

The  Length  of  Stump  must  depend  on  the  conditions  encountered.  As 
before  mentioned,  material  fora  suitable  flap  is  of  greater  value  than  length 
of  bone.  It  is  evident,  however,  that  the  longer  the  stump,  the  greater  the 
leverage  will  be  by  which  an  artificial  limb  is  manipulated.  On  the  other 
hand,  additional  length  of  bone  in  the  lower  third  of  the  femur  and  tibia 
is  of  less  value  than  at  higher  points.  The  shorter  the  stump,  the  greater  is 
the  value  of  each  fractional  inch  of  bone.  What  might  be  sacrificed  with- 
out injury  to  the  patient  in  the  lower  third  of  a  long  bone,  might  prove  of 
great  value  in  the  upper  third. 

Irrespective  of  old-time  custom  and  usage,  the  surgeon  should  not  hesi- 
tate to  select  that  point  for  his  amputation,  and  adopt  that  method  and 
technique  that  will  best  conserve  the  interests  of  the  patient. 

Stephen  Smith,  writing  upon  this  question,  says:  "The  point  of  ampu- 
tation should  not  in  all  cases  be  the  one  that  is  farthest  from  the  trunk, 
and  when  an  amputation  nearer  the  trunk  will  give  a  better  stump,  the 
danger  of  the  wound  is  not  so  much  greater,  generally,  as  to  forbid  the 
slightly  increased  risk  for  the  lifelong  advantage  gained,  and  surgeons  who 
are  not  qualified  to  select  the  proper  point  of  amputation  or  form  a  well- 
shaped  stump,  have  already  been  judiciously  condemned." 

Whether  the  flaps  be  antero-posterior  or  lateral,  one  should  be  longer 
than  the  other,  so  that  the  cicatrix  may  be  located  to  one  side  of  the  end  of 
the  bone.  This  not  only  avoids  the  growth  of  adhesions  between  the  scar 
tissue  and  the  end  of  the  bone,  but  stumps  so  formed  are  less  likely  to  be 
super- sensitive.  That  the  last  mentioned  condition  may  not  exist,  nerve- 
endings  should  be  excluded  from  the  cicatrix.  All  the  nerves  should  be 
picked  up  and  drawn  out,  that  they  may  be  cut  off  at  a  point  above  the  ends 
of  the  severed  muscles. 

Before  the  excision  of  the  bone,  it  should  be  separated  from  the  perios- 
teum, and  the  latter  turned  back  like  a  cuff,  that  it  may  be  utilized  to  cover 
the  sawn  end  of  the  bone.  This  supplies  nature's  covering  for  all  osseous 


PROSTHETIC    SURGERY. 


1005 


structures,  and  in  most  cases  prevents  sloughing  and  consequent  flap- 
adhesion.  It  is  advisable  to  remove  the  sharp  anterior  margin  of  the  end 
of  the  bone,  particularly  in  case  of  the  tibia.  This  may  be  done  by 
making  a  primary  oblique  section  with  the  saw  in  a  downward  direc- 
tion, cutting  about  one  quarter  through  the  bone  and  then  intersecting  the 
inner  terminal  of  this  line  with  a  transverse  cut. 

In  stumps,  other  than  end-bearing,  a  cone  shape  should  be  secured 
wherever  possible.  In  such  cases  the  weight  of  the  patient  is  borne  by 
lateral  pressure  on  a  conical  socket,  together  with  such  bearings  as  may  be 
secured  by  the  head  of  the  bone  at  the  knee-joint,  and  the  ischio-perineal 
region.  The  principle  involved  here  is  the  same  as  if  one  were  to  grasp 
the  limb  of  a  friend  with  both  hands  below  the  calf  and  attempt  to  lift  him 
from  the  floor.  The  decrease  in  diameter,  or  conical  shape,  furnishes  the 
resistance  necessary  to  properly  apply  the  force. 

As  the  internal  diameter  of  a  well-formed  socket  decreases  from  above 
downward,  and  as  its  weight-supporting  power  depends  largely  upon  the 
lateral  pressure  of  the  stump  against  its  converging  walls,  it  is  evident  that 
if  the  stump  be  conical,  it  will  distribute  the  weight  or  pressure  surface 
over  a  larger  expanse  of  the  limb.  These  sockets  are  carved  or  cut  from  the 
inside  and  so  shaped  that  they  fit  the  exterior  or  skin  surface  of  the  stump 


Figure  2379.    Artificial  Leg  for  Amputation 
below  the  Knee. 


Figure  2380.    Artificial  Leg  for  Amputation 
in  or  above  the  Knee  Joint. 


as  accurately  as  a  kid  glove  fits  the  hand.  Consequently  the  nearer  the 
stump  approaches  a  circular  form,  and  the  more  nearly  free  it  is  from  all 
uneven  surfaces  and  redundant  tissue,  the  more  perfectly  it  can  be 
adjusted. 

In  thigh  amputations  in  the  upper  third  of  the  bone  we  would  advise  the 
surgeon  to  assume  some  risk  in  his  efforts  to  secure  the  longest  possible 
stump,  while  in  the  middle,  and  particularly  in  the  lower  third,  no  such 


1000  PROSTHETIC    SURGERY. 

efforts  are  necessary.  In  this  class  of  cases  the  weight  is  borne  by  a  con- 
ical socket  and  by  pressure  on  the  ischio-perineal  region. 

The  thigh  socket,  shown  by  figure  2381,  conveys  in  a  meager  way  the 
manner  in  which  the  pressure  is  distributed  over  a  large  amount  of  surface. 
Thigh  stumps  are  usually  cone-shaped,  and  if  of  reasonably  firm  tissue, 
much  pressure  can  be  borne  by  them,  thus  relieving  in  part  the  weight  to 
be  carried  by  direct  contact  with  the  pelvis.  It  will  be  readily  seen  that 
the  longer  the  stump,  the  less  the  amount  of  antero-posterior,  or  lost 
motion,  and  therefore  the  more  quickly,  and  the  more  perfectly  will  the 
substituted  part  respond  to  the  action  of  the  natural  portion. 

In  amputations  in  and  about  the  knee-joint,  there  is  still  a  diversity  of 
opinion  among  prostheticians  as  to  the  best  point  of  selection.  As  before 
mentioned,  an  end-bearing  stump,  such  as  may  be  secured  by  amputating 
in  the  contiguity  of  the  limb  is  preferable  to  one  at  a  higher  point.  Not 
only  this,  but  if  the  condyles  be  preserved,  they  may  be  utilized  as  a  means 
for  the  attachment  of  an  artificial  limb.  Some  one  of  the  various  methods 
of  disarticulation  would,  therefore,  seem  preferable,  and  are,  we  believe, 
advised  by  the  ablest  prostheticians.  It  is  essential,  however,  that  the 
stump  be  adapted  to  end-pressure,  as  otherwise  it  would  have  been  better 
had  the  amputation  been  made  above  the  condyles.  The  point  of  selection 
in  such  a  case  should  be  about  three  inches  above  the  articulation.  This 
point  furnishes  the  greatest  amount  of  socket-bearing  surface  without  inter- 
fering with  the  insertion  of  the  cylindrical  joint-iron  exhibited  in  fig- 
ure 2378. 

Disarticulations  present  one  disadvantage  in  that  the  newly-formed 
femur  becomes  lengthened  by  the  addition  of  the  artificial  portion.  As  the 
lower  leg  is  correspondingly  shortened,  the  defect  is  quite  noticeable  when 
the  patient  is  in  a  sitting  posture  with  the  leg  flexed.  It  is  also  a  fact  that 
inexperienced  artificial  limb  makers  find  it  more  difficult  to  satisfactorily 
adjust  limbs  following  contiguital  operations  than  when  the  amputation  is 
made  at  a  higher  point. 


Figure  2381.    Showing  Sectional  View  of  Thigh  Socket. 

Gritti's  supracondyloid  operation,  in  which  the  excised  face  of  the 
patella  is  attached  to  the  sawn  end  of  the  bone,  furnishes  an  ideal  method 
in  cases  where  there  is  a  lack  of  material  for  an  ample  flap,  or  where  injury 
to  the  condyles  precludes  the  preservation  of  the  latter. 

In  amputations  below  the  knee,  a  stump  may  be  either  too  short  or  too 
long.  A  stump  when  too  short  is  not  only  often  retracted,  but  it  is  inclined 
to  move  in  the  socket  of  an  artificial  limb,  resulting  not  only  in  a  large 
amount  of  antero-posterior,  or  lost,  motion,  but  a  frequent  tendency  to  slip 


PROSTHETIC    SURGERY.  1007 

out  of  place.  A  long  stump,  extending  to  or  nearly  to  the  malleoli,  not 
only  interferes  with  the  insertion  of  the  better  forms  of  ankle-joint 
mechanism,  but  in  most  patients  there  is  not  a  sufficient  amount  of  well- 
nourished  tissue  to  form  healthy  flaps. 

Ankle-joint  operations  should  be  attempted  only  when  it  is  possible  to 
secure  a  perfect  end-bearing  stump,  for  under  the  most  favorable  circum- 
stances it  is  still  an  open  question  whether  they  possess  any  advantage  over 
an  amputation  at  the  point  of  selection. 

If  the  injury  or  disease  necessitating  the  amputation  is  likely  in  any 
way  to  result  in  ankylosis  of  the  knee-joint,  operation  through  the  tibia 
should  be  abandoned  for  one  in  the  contiguity  of  the  limb.  While  it 
would  be  an  easy  task  to  construct  a  limb  without  a  knee-articulation,  which 
would  enable  the  patient  to  walk  as  well  as  patients  with  stiff  knees  who 
have  not  suffered  amputation,  yet  the  inconvenience  and  unsightly  appear- 
ance of  such  a  limb  will  not  warrant  the  preservation  of  a  tibial  stump. 
Marks  advises  that  "If  there  is  limited  motion  in  the  knee  and  there  is  a 
possibility  of  improvement,  and  a  good  flap  can  be  obtained,  it  is  well  to 
save  the  knee,  and  as  much  of  the  leg  as  possible. ' ' 

It  is  evident  that  in  tibial  stumps,  the  weight  of  the  patient  must  be 
supported  either  by.  the  calf  of  the  leg  or  the  head  of  the  bone,  and  a  bear- 
ing must  be  secured  of  such  firmness  that  contact  with  the  end  of  the 
stump  is  not  necessary. 

Generally  the  fibula  should  be  cut  from  half  an  inch  to  an  inch  shorter 
than  the  tibia  bone.  This  not  only  provides  a  stump  more  conical  in  form, 
but  it  has  been  demonstrated  that,  in  many  patients,  there  is  an  absorption 
of  the  osseous  structures  in  the  tibia  following  amputation  without  corre- 
sponding action  in  the  fibula.  The  cause  for  this  condition  is  not  plain, 
unless  it  be  a  lack  of  nourishment  and  consequent  atrophy.  We  can  only 
urge  the  fact  that  we  have  examined  several  patients  with  protruding 
fibulae,  and  instances  are  on  record  where  it  has  been  found  necessary  to 
re-amputate  this  bone.  When  only  a  short  fragment  of  the  fibula  remains,  it 
will  be  better  to  excise  it.  This  will  not  only  leave  a  more  conical 
stump,  but  will  decrease  the  dangers  of  inflammation  by  pressure  on  the 
interosseous  space. 

In  all  amputations  between  the  tibio-tarsal  and  tarso-metatarsal  articula- 
tions it  is  essential  that  the  surgeon  provide  for  an  end-bearing  stump,  not 
only  painless,  but  free  from  contraction,  for  even  under  the  most  favora- 
ble circumstances,  none  but  the  best  prostheticians  are  able  to  construct 
satisfactory  appliances  in  this  class  of  cases.  As  a  matter  of  record,  a  large 
percentage  of  these  patients  are  rendered  more  or  less  helpless  because 
these  conditions  are  not  complied  with.  Rather  than  attempt  to  utilize  a 
stump  of  this  character  in  which  the  nerves  are  included  in  the  cicatrix  or 
the  latter  is  adherent  to  the  end  of  the  bone,  the  patient  would  better  have 
suffered  amputation  at  what  is  known  as  the  point  of  selection,  or  one 
necessitating  a  complete  artificial  leg.  In  operations  between  these  points 
the  surgeon  is  called  on  for  the  exercise  of  the  greatest  amount  of  skill, 
as  is  evidenced  by  the  large  number  of  patients  who,  if  able  to  wear  an 
artificial  limb  at  all,  can  do  so  only  with  pain  or  discomfort. 

Viewed  as  a  simple  piece  of  mechanism,  the  foot  consists  of  a  skillfully 
arranged  arch,  the  calcaneum  forming  the  abutment  of  one  side,  the  tarsal 
and  metatarsal  bones  the  other,  with  the  astragalus  acting  as  the  keystone 
receiving  the  weight  of  the  body  and  transmitting  the  same  to  the  various 
bones  forming  the  arch.  The  construction  of  this  peculiar  arch  renders  it 


1008  PROSTHETIC    SURGERY. 

extremely  elastic,  its  function  in  walking  being  to  assist  in  breaking  the 
shock  produced  when  the  limb  changes  from  a  passive  to  an  active  condi- 
tion. This  occurs  at  the  moment  that  the  foot  is  planted  on  the  floor  or 
ground,  ready  to  receive  the  weight  of  the  body  when  forced  forward  by  the 
propelling  limb,  which  is  then  obliquely  extended  to  the  rear.  In  amputa- 
tion of  the  anterior  portion  of  the  foot,  it  is  just  as  certain  that,  in  case  any 
of  the  bones  necessary  to  the  maintenance  of  this  arch  are  removed,  or  the 
plantar  fascia  severed,  the  usefulness  of  the  natural  arch  will  be  destroyed, 
as  it  is  true  that  the  leaving  out  of  a  single  stone  from  the  span  of  an  arch 
will  permit  it  to  fall.  As  a  result,  Lisfranc's,  Key's,  Forbes',  Chopart's, 
and  all  similar  operations,  leave  the  patient  with  a  foot  that  is  of  no  value, 
except  to  carry  weight. 

The  foot,  viewed  simply  as  a  member  of  the  lower  limb,  is  a  triangular 
lever  pivoted  on  the  astragalus  and  capable  of  flexion  and  extension,  the 
former  produced  by  the  action  of  the  flexor  muscles,  having  their  insertion 
anterior  to  the  transverse  tarsal  joint,  the  latter  by  the  tendo  Achillis 
acting  on  the  calcaneum.  The  foot  is  therefore  the  lever,  the  ground  the 
fulcrum,  the  tendo  Achillis  the  power,  and  the  body  the  weight  to  be 
moved.  The  'tendo  Achillis  being  at  one  end  of  the  lever  and  the  flexors 
at  the  other,  with  the  weight  between  them,  it  follows  that,  in  Lisfranc's, 
Key's,  Forbes'  and  Chopart's  operations,  it  is  necessary  to  sever  all  or  the 
greater  portion  of  the  flexors,  while  the  extensor,  the  tendo  Achillis,  is 
permitted  to  remain.  As  a  result,  in  this  class  of  cases  there  is  often  more 
or  less  contraction  of  the  gastrocnemius  and  soleus  muscles  and  consequent 
drawing  downward  of  the  end  of  the  stump,  a  condition  difficult  to  meet 
in  the  construction  of  an  artificial  limb. 

A  study  of  the  physiology  of  locomotion  will  demonstrate  that  the  foot 
in  such  cases,  besides  having  lost  its  elasticity  and  being  deprived  of  much, 
if  not  all,  of  its  power  of  flexion,  is  so  shortened  that,  when  in  an  active 
state  at  the  time  when  its  limb  is  inclined  obliquely  backward,  it  can  not  be 
used  as  a  lever  or  propeller  by  which  the  body  is  advanced  to  a  position 
perpendicularly  over  the  forward  limb.  This  is  important,  for  the  loss  of 
a  portion  of  a  foot,  unless  fully  compensated  by  the  maker  of  artificial 
limbs,  necessitates  the  taking  of  a  shorter  step,  and  a  greater  flexion  of 
the  knee  of  the  sound  limb,  requiring  a  consequent  lifting  of  the  entire 
trunk  when  it  passes  over  the  active  limb.  This  raising  of  the  body  with 
every  step  requires  much  additional  labor,  and  causes  the  limp  so  notice- 
able in  many  patients  who  have  suffered  amputations  of  this  class.  These 
are  conditions  that  the  prosthetician  is  called  upon  to  meet,  and  it  is  to  be 
regretted  that  a  large  percentage  of  this  class  of  patients  present  compli- 
cations that  preclude  the  application  of  satisfactory  artificial  legs. 

As  previously  shown  by  statistics,  following  amputations  by  various 
surgeons,  and  in  the  hands  of  the  majority  of  prostheticians,  the  wants  of 
the  patient  are  as  a  rule  better  served  by  amputation  at  the  junction  of  the 
lower  and  middle  thirds  of  the  tibia.  While  making  this  statement,  it  is 
acknowledged  that,  with  proper  care  on  the  part  of  the  surgeon  in  making 
the  amputation,  and  under  the  direction  of  a  skilled  manufacturer,  better 
results  may  be  obtained  with  any  one  of  the  end-bearing  stumps  previ- 
ously referred  to. 

Owing  to  the  difference  between  the  service  required  of  an  artifi- 
cial arm  and  tha  t  required  of  a  leg,  it  follows  that  the  rules  which  should 
govern  the  surgeon  in  amputating  in  the  former  case,  do  not  apply  to  the 
latter. 


PROSTHETIC    SURGERY.  1009 

In  a  stump  for  prehensile  purposes,  as  many  articulations  should  be 
preserved  as  possible,  for  a  single  finger,  or  even  a  portion  of  a  finger,  is  of 
far  greater  value  to  the  patient  than  a  whole  artificial  hand.  In  oper- 
ations in  the  hand,  the  surgeon  would  be  justified  in  assuming  the  risks  of  a 
secondary  operation,  provided  there  was  a  reasonable  chance,  by  so  doing, 
of  saving  an  additional  part  of  this  most  valuable  member.  As  McHatton 
has  well  said:  "It  is  far  more  creditable  to  the  surgeon  to  have  saved  even 
a  portion  of  a  finger  than  to  have  amputated  a  dozen  whole  ones. ' '  Further, 
there  are  many  cases  of  injuries  of  the  arm  and  forearm  necessitating 
great  loss  of  muscular  tissue  and  sections  of  bone,  and  possibly  resulting  in 
immobilized  joints,  yet  if  carefully  treated,  the  limb,  though  badly  crippled, 
may  be  preserved,  and  prove  of  much  more  service  to  the  patient  than  the 
best  substitute  ever  made.  An  artificial  arm  invariably  presents  an  un- 
sightly and  unlifelike  appearance,  and  with  its  awkward,  rigid  form  and 
general  helplessness  is  always  a  source  of  discomfort  and  annoyance. 

Immediately  following  amputation,  and  until  a  substitute  is  applied,  leg 
stumps  should  be  kept  well  bandaged,  not  only  to  prevent  retraction,  but 
to  promote  the  absorption  of  redundant  material  and  to  prevent  the  forma- 
tion of  adipose  tissue.  Unfortunately  there  is  a  disposition  on  the  part  of 
many  stumps  to  hypertrophy,  a  condition  that  invariably  proves  the  source 
of  much  trouble  in  the  application  of  an  artificial  limb.  This  condition 
may  be  prevented  by  proper  bandaging,  readjustment  being  made  from 
day  to  day,  as  the  bandage  is  removed  and  reapplied.  Much  benefit  may  be 
derived  from  massage  treatment  applied  daily  to  the  stump,  in  order  to 
retain  the  normal  sense  and  activity  of  the  muscles,  as  well  as  to  harden  the 
integument,  thus  decreasing  its  sensibility,  and  lessening  its  liability  to 
excoriation. 

An  erroneous  impression  prevails  among  surgeons  that  a  certain  and  often 
considerable  time  should  elapse  between  the  date  of  amputation  and  the 
adjustment  of  an  artificial  limb.  During  this  period  the  non-use  of  the 
stump  may  result  not  only  in  hypertrophy,  but  in  a  condition  of  still  greater 
disadvantage,  atrophy.  If  a  stump  is  allowed  to  remain  as  a  useless 
dependent  member  without  service  or  functions,  the  muscles  soon  waste 
away  and  lose  their  activity,  the  tissues  become  in  a  measure  devital- 
ized, and  general  impairment  of  function  results.  In  the  presence  of  these 
conditions  it  is  no  wonder  that  patients,  months — or  as  is  sometimes  the 
case,  years — after  an  amputation,  find  that  they  can  adjust  themselves  to 
the  new  conditions  that  exist  when  attempting  to  wear  a  substitute  only, 
if  at  all,  with  the  greatest  difficulty.  The  proper  time  to  apply  an  artificial 
leg  is  the  earliest  moment  after  the  stump  has  healed  that  it  will  bear 
contact  with  the  stump  socket. 


INDEX. 


Page. 

Absorbent  Cotton 356 

Dressings 354 

Gauze 354 

Wool 359 

Acid  Drop  Bottle 77 

Acoumeter 775 

Acupressure  Forceps 306 

Needles 306 

Adapter,  Electric 258 

Adhesive  Plasters 350 

Adjuster,  Silver  Wire 505 

Air  Pumps 631 

Receivers 634 

Albuminometer 79 

Alcohol  Lamp 76 

Alternator,  Electric 257 

Ambulances. 83,  914 

Analysis,   Urinary 73 

Anastomosis  Instruments 429 

Anesthesia,  General 
Local 

Ankles,  Weak,  Apparatus  for 991 

Anthropometry 69 

Antiseptic  Compresses 307 

Antrum,  Tapping  of 759 

Apparatus,  Suspension 935 

Apparel     Equipment      of      Surgeons, 

Nurses,  etc 133 

Application  and  Extraction  of  Heat...  222 

Applicators,  Cocaine  for  Uvula 653 

Ear 785 

Funis,  Ring 855 

Laryngeal 652 

Nasal 725 

Urethral,  Female 467 

Urethral,  Male 595 

Uterine 455,  511 

Aprons,  Surgeon's 135 

Arterial  Compression ; 292 

Artery  Forceps 294 

Artificial  Respiration 215 

Ascertaining  Sensitiveness  of  Skin 68 

Aspirating  Needles 206 

Trocars 207 

Aspiration 201 

Aspirators 201 


Page. 

Astigmometer 853 

Atomizers 643 

Steam 646 

Audiphone 798 

Aural  Surgery 761 

Auscultation 48 

Back  Rests 95 

Bags,  Ice 226 

Petersen's 558 

Politzer's 770 

Bandage  Roller 362 

Roller  for  Plaster  of  Paris  Band- 
ages    921 

Bandages 361 

Adhesive 364 

Elastic 365 

Plaster  of  Paris 920 

Roller 361 

Rubber 365 

Triangular 364 

Basins,  Dressing 132 

Wash 93 

Baths,  Electrical 250 

Portable 88,  228 

Battery  Accessories 239 

Batteries,  Cabinet 247 

Electric 235 

Primary 236 

Storage 262 

Beakers 76 

Bed  Trays 95 

Bedding,  Hospital 89 

Bed-pans 93 

Beds,  Hospital 89 

Stretcher 967 

Bedside  Stands 90 

Tables 95 

Utensils 92 

Binder,  Abdominal 429 

Binder's  Board 919 

Bistouries 276 

Lithotomy 563 

Bladder,  Applications  to 554 

Examination  of 530 

Flushing  of 551 


1010  . 


INDEX. 


1011 


Page. 

Bladder,  Foreign  Bodies  in 55° 

Puncture  of 54& 

Surgery  of 53° 

Washing  Out 55i 

Blankets,  Rubber 854 

Blood,  Examination  of 41 

Bloodletting 229 

Blow  Pipes 78 

Blunt  Hooks,  Obstetrical 869 

Uterine 495 

Bobbins  for  Ligatures  and  Sutures 326 

Bone-Chips 398 

Plates 432 

and  Joint  Surgery 367 

Bottles,  Acid  Drop 77 

Hot  Water 223 

Irrigating 122 

for  Antiseptics 143 

Tincture 129 

Wide  Mouth 129 

Bougies,  Esophageal 699 

Eustachian 788 

Laryngeal 676 

Rectal 875 

Renal 529 

Ureteral 472 

Urethral 570 

Bow-Legs,, Apparatus  for 988 

Boxes,  Catheter 545 

Fracture 937 

Glass  for  Dressings 130 

lodoform 144 

Ligature 131 

Refuse 126 

Tablet,  Corrosive  Sublimate 142 

Brush  Boxes 139 

Holder,  Urethral 596 

Trephine 393 

Brushes,    Hand 139 

Throat 650 

Brackets,  for  Artificial  Light 614 

Reflector 627 

Buckets,  Slop 93,  127 

Stomach 707 

Burner,  Bunsen 76 

Burrs,  Surgical  Engine 392 

Buttons,  Anastomosis 429 

Lead 346 

Suture 346 

Cabinets,  Dressing 115 

Instrument    .  .116 


Pajre. 

Calibrator,  Anastomosis 434 

Vaginal 451 

Calipers 72 

Camerae  Lucidse 30 

Candles,  Sulphur 145 

Canthoplasty 829 

Canulas,  Epistaxis 758 

Lachrymal 837 

Snaring 784 

Caps,  Ice 226 

Rubber  for  Nurses 136 

Capsule,  Intra-Gastric,  Reagent 707 

Cardiometers 68 

Care  of  Instruments 19 

Carriages,  Ward 115 

Carrier,  Chain-Saw 380 

Drainage  Tube 315 

Ligament 509 

Ligature,  Transfixion 482 

Suppository,   Bladder 554 

Cases  for  Knives 20 

Operating,  General 408 

Operating,  Military 907 

Pocket 408 

Castration 607 

Cataract 812 

Catgut 318 

Sterilization 171 

Catheter  Boxes 54  5 

Double  Channel 553 

Elastic  Metal 542 

Elastic  Web 535 

Eustachian 771 

Female 463 

Guide 542 

Holder 545 

Lubricant 539 

Pocket  Case 544 

Renal 469 

Rigid 543 

Self-Retaining,  Female 494 

Soft  Rubber 541 

Syringe,  Bladder 554 

Tied  in 545 

Tunneled 585 

Tympanic 773 

Ureteral,  Female 469 

Catheterism,  Male 535 

Female  Ureteral 468 

Catlins,  Amputating 401 

Caustic  Applicators,  Laryngeal 652 

Holder,  Urethral 595 


1012 


INDEX. 


Page. 

Caustic  Holders,  Uterine 512 

Cauterization,  Mechanical 218 

Cautery  Electrodes 264 

Galvano- 261 

Handle 263 

Lamp 219 

Primary  Battery 262 

Snare 263 

Storage  Battery 262 

Thermo- 220 

Cells,  Battery 237 

Cephalotribe 874 

Cephalotripsy 874 

Centrifugal  Sedimentation 38 

Centrifuge 39 

Cervix,  Amputation  of 508 

Cesarean  Section 862 

Chain  Saw 379 

Saw  Carrier 380 

Chairs,  Gynecological 436 

Hospital 91 

Patients' 610 

Chalazton  Cysts,  Removal  of 831 

Chamber 93 

Chatelaines  for  Nurses 136 

Cheek-Retractor 694 

Chemical  Flasks 76,  129 

Chest  and  Lungs,  Examination  of 45 

Chests,  Military 909 

Chisels,  Bone 370 

Mastoid 779 

Nasal 745 

Chloroform  Drop  Bottles 182 

Inhalers 180 

Circumcision 603 

Clamps,  Eustachian  Catheter 772 

Cautery 484 

Hemostatic,  Nasal 743 

Hysterectomy 493 

Pedicle 482 

Phimosis 603 

Rectal 890 

Scrota! 606 

Uvula 654 

Cleaner,  Cover  Glass 35 

Cleft  Palate 693 

Club-Foot,  Apparatus  for 992 

Coats.  Spectators' 134 

Coil,  Ruhmkorff 269 

Tesla 269 

Coils,  Water 228 

Collars,  for  Spinal  Curvature 966 


Page. 

Commode 93 

Compress  Heater 225 

Protector 225 

Compresses,  Antiseptic 307 

Compression  Forceps 421 

Condensers,  Microscopical 27 

Illuminating 618 

Conductor  for  Ureteral  Urine 470 

Constrictor,  Renal 528 

Construction  of  Instruments 14 

Conversation  Tubes 796 

Converter,    Electric 257 

Cornea,  Tattooing  of 818 

Cornets,    Ear 798 

Cotton,  Absorbent 356 

Carriers,  Ear 769 

Carriers,  Nasal 722 

Holder,    Urethral 595 

Holding  Forceps 651 

Ordinary 359 

Counter-Irritation 233 

Pressure  Instruments 505 

Couplers,  Anastomosis 429 

Cover  Glasses 34 

Glass  Cleaner 35 

Glass  Forceps 35 

Glass  Gauge 35 

Glass  Holder 35 

Operating  Table in 

Patient's in 

Cradle  for  Supporting  Trunk 112 

Cranial  Fissures,  Location  of 66 

Cranio- Facial  Angle  Instrument 72 

Cranioclasts 873 

Craniotomy 870 

Cricotomy 685 

Crochets,  Craniotomy 872 

Croup  Kettle 647 

Crutches,  Perineal 109 

Cuirass,  Spinal 970 

Cupping,   Dry 232 

Glass 232 

Cups,  Spit 93 

Curettage,  Uterine 473 

Curettes 77 

Ear 785 

Mucus 456 

Nasal 738,  752,  758 

Nasal,  Foreign  Body 758 

Placenta 860 

Trachoma 828 

Uterine 473 


INDEX. 


1013 


Page. 

Current,  Electric,  Direct 257 

Electric,  Indirect 260 

Cushion,  Surgical in 

Cuspidor 93 

Holder 61 1 

Cut-Offs,  Air 635 

Irrigating 1 22 

Cutter,  Stricture,  Urethral 590 

Cyrtometers 46 

Cystocele,  Appliances  for 524 

Cystoscopes 530 

Cystotomes 814 

Cystotomy,  Perineal 563 

Supra-Pubic 558 

Decapitation,  Fetal 874 

Deformities,  General  Treatment  of. ...  939 

Nasal,  Correction  of 753 

Depressors,  Tongue 61 1 

Vaginal 449 

Determining  Body  Temperature 57 

Diagnostic  Instruments,  General......  22 

Diaphragms 28 

Dilators,  Esophageal 4 700 

Lachrymal 835 

Laryngeal 676 

Meatus 581 

Nasal 748 

Preputial 604 

Rectal 892,  894 

Tracheotomy 689 

Urethral,  Female 464 

Urethral,  Male 585 

Uterine 456,  856 

Vaginal 494 

Direct  Current 235 

Current  Dynamo 257 

Directors 287 

Lachrymal 837 

Rectal 887 

Divulser,  Pterygium 821 

Strabismus 823 

Dishes,  Evaporating 77 

Displacement,  Uterine 516 

Douches,  Nasal 727 

Drainage  Tube,  Abdominal 427 

Tube,  Antrum 759 

Tube  Carriers 3m 

Tube,  Decalcified  Bone 313 

Tube,  Double 315 

Tube  en  Chemise 566 

Tube,  Glass 317 


Page. 

Drainage  Tube,  Perineal 565 

Tube,  Soft  Rubber 313 

Tube,  Supra-Pubic 561 

Tube  Syringe 428 

Tube  Trocar 316 

Drains,  General 313 

Dressing  Basins 132 

Cabinets 115 

Forceps 283 

Tables 113 

Dressings 350 

Absorbent 354 

Drills,  Antrum 760 

Bone 389 

Nasal 745 

Surgical  Engine 392 

Trephine 390 

Drop  Bottles,  Chloroform 182 

Bottles,  Ether 181 

Droppers 75 

Dry  Cupping 232 

Dynamo.  Direct  Current 257 

Indirect  Current 260 

Dynamometer 69 

Ecraseur,  Renal 528 

Uterine. . .      .  .<v 487 

Elastic  Compression  <£>f  Limb 290 


Constriction  oWLirnb 291 

Elbow,  Ankylosis.  7/>.     ^ 977 

Electric  Adapter. .    .?<)...  <5>...  .  258 

*•  s  f     *o  j 

Alternator \R  . .  .^* 257 

Bath ^  .  .A 250 

Batteries ^  .  .^ 236 

Converter $..-..  /tx.  -  257 

Transformer '.<&< 257 

Electro-Magnet,  Eye IV...  832 

Electro-Therapeutics 235 

Electrodes,  Cautery 264 

Ovarian 515 

Rectal 883 

Stomach 714 

Urethral 580 

Uterine 514 

Vaginal 513 

Electrolysis 255 

Needles 255 

Elevators,  Cranial 397 

Lid 805,  826 

Periosteal 381 

Uterine 516 

Uterine,   Suspension 516 


1014 


INDEX. 


Page. 

Emballometer , 57 

Embryotomy 870 

Encioscopes 574 

Engines,  Surgical 390 

Surgical,  Foot 391 

Enterorrhaphy 429 

Entropion 824 

Enucleation  of  Eyeball 820 

Enucleator,  Myoma 491 

Epiglottis  Retractor 630 

Epistaxis 758 

Esophageal  Stricture,  Treatment  of. ...  700 

Foreign  Bodies,  Removal  of 700 

Surgery 698 

Esophagoscopes 698 

Esopnagotomes 700 

Esthesiometer 68 

Ether  Drop  Bottles 181 

Inhalers 178 

Ethyl  Chloride 189 

Evacuators,  Calculi 557 

Evaporating  Dishes 77 

Evisceration,  Eyeball 819 

Fetal 874 

Examination,  Blood 41 

Chest  and  Lungs 45 

Exenteration,  Eyeball 819 

Exhauster,  Cataract 816 

Exostoses,  Removal  of 786 

Exploration,  Tissue 66 

Exploring  Needles 66 

Trocars 67 

Extractors,  Foreign  Body,  Esophageal.  70 

Foreign  Body,  Throat 667 

Intubation  Tube 680 

Shot 407 

Tympanum  Fragments 791 

Tissue 67 

Eye,  Examinations  of 839 

Foreign  Bodies,  Removal  of 832 

Illumination  of 839 

Eye  Pieces 27 

Felt  Hatter's 918 

Poroplastic 918.  960 

Fibroids,  Uterine.  Treatment  ot 485 

Fistulatomes 885 

Fistulas,  Rectal,  Treatment  of 885 

Vaginal,  Closure  of 506 

Flask,  Chemical 76,  129 

Flat- Foot,  Apparatus  for gqb 

Floats,  Glass  ..  .120 


Page 

Fluoroscope 267 

Fomentations,  Hot 224 

Forceps,  Acupressure 306 

Advancement 824 

Anastomosis 433 

Anastomosis,  Button 432 

Artery .-;..  294 

Avulsion,  Bladder 562 

Bladder,  Foreign  Body 550 

Bone-Cutting 383 

Bone-Gouging 385 

Bone-Holding 386 

Bullet 405 

Calculus,  Renal 529 

Canula,  Intra-Tracheal 690 

Capsule 814 

Cerumen 769 

Chalazion 831 

Clarnp,  Eyelid 824 

Compression 421 

Cotton-Holding,  Laryngeal 651 

Cotton-Holding,  Female  Urethral.  467 

Cover  Glass 35 

Craniotomy 1 872 

Cutting,  Nasal 738 

Dressing,  Abdominal 423 

Dressing,  Eye 805 

Dressing,  General 283 

Dressing,  Nasal 731 

Dressing,  Rectal 883,  884 

Dressing,  Uterine 454 

Ear 769 

Entropion 824 

Epiglottis 630 

Epilating 830 

Esophageal 701 

Fixation 807 

Foreign  Body,  Ear 787 

Foreign  Body,  Throat 667 

Foreign  Body,  Urethral 601 

Harelip 897 

Hemostatic,  Self-Grasping. 302 

Hemostatic,  Slide-Catch 300 

Hemostatic,  Snap-Catch 294 

Hemostatic,  Spring-Catch 302 

Hysterectomy  Clamp 492 

Intestinal 434 

Iris 810 

Lid 824 

Lid-Everting 827 

Lithotomy 559 

Membrane..                                     ...  682 


IN  ni-x. 


1015 


Page. 

Forceps,  Morcellement 489 

Myomectcmy 488 

Obstetrical 863 

Ovum 856 

Packing 475 

Pedicle 480 

Phimosis 603 

Placenta 859 

Polypus,  Ear 780 

Polypus,  Nasal 749 

Polypus,  Uterine 486 

Punch,  Nasal 753 

Rhinoplastic 755 

Tissue 281 

Sac 479 

Seizing,  Nasal 732 

Septum,  Punch 753 

Sequestrum 388 

Sequestrum,  Ear 795 

Shot-Compressing 347 

Snare 784 

Splinter 283 

Sponge-Holding 420 

Tenaculum 452 

Tissue,  Abdominal 424 

Tongue 186 

Tonsil,  Snaring 658 

Tonsil,  Volsellum 659 

Torsion 303 

Tracheal 668 

Trachoma 828 

Traction 478 

Tumor,  Gynecological 478 

Tumor,  Throat 669 

Volsellum 423,  454,  487,  659,  660 

Wire-Shouldering 349 

Wire-Twisting 348 

Forcipressure 294 

Fork,  Counter- Pressure 505 

Forks,  Tuning 775 

Formaldehyde  Gas 145 

Sterilizers 146 

Fountain  Syringe 311 

Fractures,  Mechanical 942 

Treatment  of 915 

Frame,  Trendelenberg 105 

Funnels 76 

Gags,  Mouth 187,  655 

Mouth,  Intubation 681 

Galvanic  Batteries 236 

Galvano-Cautery 261 


Page. 

Garments,  Surgeons',  Nurses',  etc 133 

Gas,  Acetylene 616 

Brackets 614 

Gastroscopes 708 

Gauge,  Catheter 567 

Cover  Glass 35 

Gauze,  Absorbent '. 354 

Genito-Urinary  Surgery 526 

Glass  Slides.  Microscopical 33 

Glasses,  Cover 34 

Cupping 232 

Measuring 74 

Test 78 

Goniometer,  Orthopedic 942 

Vesical 468 

Gorgets 887 

Gouges,  Bone 371 

Margo  Tympani 793 

Mastoid 779 

Nasal 745 

Gowns,  Assistants' 134 

Nurses 134 

Guide,  Mastoid 779 

Guillotines,  Laryngeal 673 

Gunshot  Wound  Surgery 402 

Gutta-Percha 918 

Tissue 361 

Gynecological  Surgery 436 

Gyromele 709 

Hammers,  Percussion 55 

Harelip,  Operation 896 

Harpoons,  Tumor 67 

Head  Bands 625 

Hearing  Instruments 795 

Heart's  Beat,  Locating  Apex  of 68 

Heat,  Application  and  Extraction  of . . .  222 

Height  Measures 71 

Hemocytometers 41 

Hemoglobinometer 44 

Hemometer 43 

Hemorrhage,    Prevention    and  Treat- 
ment of 290 

Hemorrhoids.  Treatment  of 888 

Hemostatic  Forceps 294 

Hemostats,  Tonsil 664 

Hernia.  Treatment  of 898 

Hip  Supports 112 

Joint  Apparatus 978 

History  of  Instruments n 

Holders,  Catheter 545 

Cover  Glass .     35 


1016 


INDEX. 


Page. 

Holders,  Cuspidor 610 

Leg 190 

Lid 826 

Test  Tube 74 

Hooks,   Bone 388 

Decapitating 874 

Ear 786 

Foreign  Body,  Nasal. 757 

Fracture 930 

Incus 793 

Iris 811 

Lacing 957 

Ligament 509 

Patella 932 

Skin  Grafting 896 

Strabismus 821 

Strabismus,  Traction 823 

Horns,  Hearing 797 

Hospital  Bedding 89 

Beds 89 

Equipment  of 88 

Hot  Water  Bottles 223 

Cans 223 

Hydrocele,  Treatment  of 609 

Hypodermic  Injection 190 

Needles 191 

Syringes 193 

TVocars 192 

Hysterectomy 491 

Hysterorrhaphy 507 

Hysterotomy 491 

Ice  Bags 226 

Caps 226 

Ignition  Tube 326 

Illuminating  Apparatus 614 

Incisor,  Prostatic 593 

Indirect  Current  Dynamo 260 

Induced  Current 247 

Infants,  Premature,  Care  of 858 

Inflammation  of  Throat,  Relief  of 630 

Resolution  of 222 

Inhalers 647 

Chloroform 180 

Ether 178 

Nasal 730 

Injection  Apparatus 210 

Injections,  Parenchymatous 234 

Instrument  Cabinet 116 

Rolls 19 

Tables 114 

Instruments,  Care  of 19 


Page. 

Instruments,  Construction  of 14 

History  of 1 1 

How  to  Sharpen 280 

Intra- Venous  Injection 212 

Introducers,  Intubation  Tube 679 

Intubation 676 

Instrument*,  Sets  of 683 

Tubes 677 

Iridectomy 807 

Irrigating  Bottles 122 

Jars 121 

Pipes 122 

Stands 123 

Irrigation  Apparatus 227 

Bladder,  Female 524 

Urethral 599 

Uterine 510 

Vaginal 509 

Wound 311 

Irrigators 121 

Stomach,  Double 713 

Urethral 599 

Uterine 510 

Jackets,   Spinal 955 

Jars,  Anatomical 129 

for  Dressings,  etc 128 

Irrigating 121 

Refuse 126 

Jury  Mast 962 

Jute 360 

Kangaroo  Tendon 320 

Tendon,  Sterilization  of 175 

Keratomes 809 

Kettle,  Croup 647 

Kidneys,  Floating,  Appliances  for 526 

Surgery  of 526 

Knee-joint,  Affections  of 983 

Knife  Blade  Sheaths 20 

Boxes 21 

Shields 20 

Knives,  Amputating 400 

Canaliculus 836 

Cartilage 401 

Cataract 813 

Ear 790,  791 

Hysterectomy 494 

Iridectomy 809 

Iris 809 

Laryngeal 670 

Metacarpal 401 


INDEX. 


1017 


Page. 

Knives,  Minor  Operating 275 

Myomectomy 489 

Plaster  of  Paris  Bandage 922 

Pocket,  Military 907 

Septum 737 

Staphylorrhaphy 694 

Stricture,  Lachrymal 836 

Symphyseotomy 862 

Tonsil 659 

Trachelorrhaphy 503 

Tympanum 790,  791 

Knock-Knee,  Apparatus  for ...  986 

Lachrymal  Duct,  Diseases  of 833 

Lamp,  Alcohol 76 

Antrum 759 

Cautery 219 

Stomach 708 

Student's 614 

Lance,  Renal 529 

Laparotomy 415 

Laryngeal  Instruments  in  Sets 674 

Dumlsion 684 

Laryngectomy 691 

Laryngoscope,   Electric 616 

Laryngotomy 685 

Lateral  Curvature  of  Spine 975 

Lavage,  Stomach 712 

Leeches,  Artificial 231 

Leeching 230 

Leg  Holder 109 

Extensions  for 997 

Paralysis  of 982 

Lens  for  Eye  Examinations 833 

Lenses  for  Eye  Examinations,  Sets. . . .  839 

Lever,  Davy's 294 

Ligation 304 

Ligature  Carriers 278,  305,  887,  889 

Carriers,  Transfixion 482 

Scissors 344 

Limb,  Elastic  Compression  of 290 

Elastic  Constriction  of 291 

Limbs,  Artificial 999 

Lingual  Tonsil,  Treatment  of 665 

Lint 358 

Cloth 385 

Marine 360 

Paper 359 

Lister's  Protective 360 

Lithoclasts 560 

Litholapaxy 555 

Lithotomy 563 


Page. 

Lithotrites 555 

Litmus  Paper 77 

Litters 85 

for  Deformity  Cases 968 

Military 913 

Locating  Apex  of  Heart's  Beat 68 

Location  of  Cranial  Fissures 66 

Lordosis 971 

Mackintosh 361 

Mallets 375 

Manometers 48,  771 

Marine  Lint 360 

Measures,  Height 71 

Slide 71 

Tape 45 

Measuring  Glasses 74 

Meatometer 581 

Meatotomes 581 

Meatotomy 580 

Mechanical  Aids  in  Diagnosis 22 

Cauterization 218 

Membrana  Tympani,  Perforation  of ...  789 

Mensuration 45 

Micrometers 29 

Microscopes 23,  26 

Microscopy 22 

Microtomes : 31 

Military  Surgery 904 

Milliamperemeters 240 

Minor  Operative  Surgery 270 

Mirrors,  Ear 762 

Head 622 

Infra-Glottic 691 

Intra-Urethral 577 

Middle  Ear 774 

Throat 627 

Models,  Eye 843 

Moose  Pappe 359 

Motor,  Surgical 390 

Mounting  of  Microscopic  Objects 31 

Mouth  and  Throat,  Examinations  of . . .  610 

and  Throat  Surgery 610 

Gags 187,  655 

Gags,  Intubation 681 

Shields 683 

Myomectomy,  Vaginal 485 

Nail  Cleaners 141 

for  Fractures 398 

Nasal  Surgery 718 

Naso-Pharyngeal  Surgery 718 


1018 


INDEX. 


Page. 

Nebulizers 640 

Stomach 714 

Needle  Bottles 335 

Boxes 335 

Cases 338 

Holders 337 

Holders,  Eye 806 

Needles,  Abdominal  Section 426 

Aspirating 206 

for  Bloodless  Amputation 306 

Cataract 816 

Cervical 504 

Eye 806 

Exploring • 66 

Exploring,  Renal 529 

Fistula 332 

Glover's 335 

Hagedorn's 333 

Hypodermic 101 

Hysterectomy 498 

Intestinal 435 

Intra- Abdominal 425 

Nephropexy 527 

Paracentesis 819 

Pedicle 482 

Perineorrhaphy 499 

Schnetter's. 335 

Self-Threading 335 

Silver  Wire 344 

Surgical,  General 331 

Tattooing 819 

Trachelorrhaphy 504 

Transfixion,  Nasal 737 

Varicocele 608 

Nephrectomy 527 

Nephrolithotomy 527 

Nephropexy 527 

Nephrotomy 527 

Nipples  for  Cleft  Palate 693 

Nitrogen  Gas  Injection  Apparatus 211 

Nitrous  Oxide  Gas 184 

Nose-Pieces,"  Microscopical 29 

Nurses'  Gowns 134 

Oakum 360 

Objectives 27 

A  Obliquimeters 72 

Obstetrical  Pads in 

Surgery 854 

Obturators  for  Cleft  Palate 693 

Oiled  Muslin 360 

Silk 360 


Page. 

Operating     Apartments     and    Equip- 
ments    97 

Cases 408 

Stools 109 

Tables 103 

Ophthalmometers 851 

Ophthalmoscopes 840 

Ophthalmostats 808 

Orthopedic  Surgery 939 

Osteoclasts 942 

Osteotomes 373 

Otophone  796 

Otoscopes 764 

Ovariotomy  by  Abdominal  Section 476 

Ox  Tendon 321 

Oxygen,  Compressed 184 

Packers 475 

Rectal 883 

Packing,    Uterine 475 

Paddings 359 

Pads,  Abdominal 309 

Kidney 526 

Surgical in 

Paper,  Litmus 77 

Paraffin 361 

Paracentesis 201 

Cornea 819 

Patient,  Cover  for in 

Patient's  Robe 134 

Patients,  Transportation  of 83 

Peg,  Ivory 398 

Pelvimeters 46,  861 

Pelvis,  Measurement  of 861 

Penis,  Surgery  of 603 

Percussion 55 

Auscultatory 57 

Hammers 55 

Stethoscopes 57 

Perforator,   Craniotomy 870 

Perforators,  Tympanum 790 

Perimeter 848 

Perineal  Crutches 109 

Pads in 

Perineorrhaphy 498 

Periosteal  Elevators 381 

Pes  Cavus,  Apparatus   for 997 

Pessaries 51? 

Anteflexion 519 

Anteversion 518 

Cystocele 525 

Prolapsus 522 


INDEX. 


1019 


Page. 

Pessaries,  Retroflexion 251 

Retroversion 520 

Phantom,  Bladder 532 

Phimosis 603 

Phonendoscopes 54 

Phorometer 846 

Photometer 848 

Pins,  Safety 366 

Pipes,  Irrigating 122 

Irrigating,   Bladder 552 

Rectal 882 

Pipettes 74 

Cocaine 834 

Pitcher,  Water 93 

Placenta,  Removal  of 859 

Plaster,  Adhesive 350 

Adhesive,  Court 353 

Adhesive,  Isinglass 353 

Adhesive,  Resin 351 

Collodion 354 

Rubber 351 

Plastic  Surgery 896 

Plates,  Bone 432 

Pleximeters 56 

Pliers,  Cutting 497 

Flat-Nose 737 

Plough,  Nasal 747 

Plug,  Artificial,  Supra-Pubic  Urethra. .   562 

Cervical 506 

Laryngeal 676 

Prolapsus,  Rectal 893 

Vaginal 507 

Pocket  Cases 408 

Pole  Changers 242 

Politzer's  Bag 770 

Polypi,  Ear,  Removal  of 780 

Portable  Baths 88 

Porte-Caustique,  Urethral 594 

Porte-Fillet 869 

Pott's  Disease 947 

Braces  for 947 

Jackets  for 955 

Pouches,  Military,  Medical 905 

Powder  Blowers 647 

Prevention  and  Treatment  of  Hemor- 
rhage     290 

Probangs,   Esophageal 699 

Esophageal,  Foreign  Body 703 

Probes 290 

Bullet 402 

Bullet,  Electric 403 

Ear 777,  793 


Page. 

Probes,  Nasal 722 

Rectal 876 

Urethral 578 

Uterine 451 

Proctoscope 877 

Prolapsus,  Rectal,  Treatment  of 893 

Prostate,   Surgery  of 602 

Prosthetic  Surgery 999 

Protective,  Lister's 360 

Protectives,  Eye 853 

Protector  for  Skin 923 

Pterygium 820 

Ptosis 829 

Pulse,  Studying  Condition  of 63 

Pumps,  Air 631 

Stomach 716 

Surgical 203 

Pupillometers 844 

Racks,  Test  Tube 74 

Raspatories 381 

Razors 140 

Microscopical 31 

Receivers,  Air 634 

Reflector  Brackets 627 

Holders 625 

Reflectors,  Head  Mirror 625 

Illuminating 618 

Repositor,  Inversion  Uterus. 523 

Repositors,  Uterine '. 516 

Resolution  of  Inflammation 222 

Respiration,  Artificial 215 

Retractors,  Abdominal 417 

Cheek 694 

Epiglottis 630 

Mastoid 778 

Minor  Operating 284 

Palate 723 

Rectal 889 

Tracheotomy 689 

Rheostats 241 

Rheotomes 241 

Rhinitis,  Treatment  of 724 

Rhinoscope 718 

Robe,  Patient's 134 

Roentgen  X-Ray 268 

Rolls,  Instrument 19 

Rotator,  Uterine 517 

Rubber  Dam 361 

Saccharometer 79 

Safety  Pins 366 


1020 


INDEX. 


Page. 
Saw,  Chain 379 

Metacarpal 376 

Nasal 743 

Operating,  General 376 

Plaster  Bandage 923 

Skull 379 

Spoon 490 

Subcutaneous 380 

Scales,  Catheter 56? 

Intubation  Tube 678 

Scalpels,  Eye 818 

Lithotomy  563 

Minor  Operating 275 

Scarificators,  Tonsil,  Lingual 665 

Trachelorrhaphy 501 

Trachoma 827 

Scarifiers 229 

Schleich's  Solution 185 

Scissors 288 

Abdominal  Wall 415 

Angular 289 

Anvil  Bone 794 

Cataract 814 

Cervical 488 

Curved  on  the  Flat 289 

Enucleation 820 

Fistula 507 

Hemorrhoidal ....  890 

Intra-Abdominal 416 

Iris 810 

Laryngeal 672 

Ligature 344 

Myomectomy 489 

Nasal 741 

Perineorrhaphy 499 

Pterygium  821 

Rectal 886,  895 

Septum 755 

Sequestrum,  Ear 795 

Silver  Wire 350 

Staphyloma 818 

Strabismus 822 

Tonsil 660 

Tonsil,  Lingual 665 

Umbilical 855 

Uvula 653 

Scoops,  Bone 367 

Bullet 407 

Cataract 815 

Ear 793 

Lithotomy 560 

Mastoid 779 


Page. 

Scoops,  Renal 530 

Screens 90 

Screws,  Oral 187 

Tumor 496 

Scrotal  Amputation 606 

Compressing  Apparatus 605 

Surgery 605 

Searcher,  Ureteral,  Female 468 

Section  Cutters 31 

Knives 31 

Sediment  Tubes 78 

Sedimentation,  Centrifugal 38 

Segregator,    Urine 471 

Septometers 730 

Serre-Noeud 497 

Serresfins 303 

Seton 233 

Shades,  Eye 853 

Sharpening  Instruments 280 

Shears,  for  Cutting  Splints 918 

Plaster  Bandage 925 

Rib 385 

Sheaths  for  Knife  Blades 20 

Shields  for  Knives 20 

Mouth 683 

Nipple 858 

Silver  Wire 505 

Shirts  for  Spinal  Jacket 958 

Shot  Compressing  Forceps 347 

Perforated 346 

Perforator 347 

Shoulders,  Round 971 

Sigmoidoscope 877 

Silk 322 

Braided 324 

Cable  Twist 324 

Floss 325 

Iron  Dyed 323 

Oiled 360 

Saddler's 324 

Sterilization 175 

Tait's 324 

Tensile  Strength  of 323 

Twisted 323 

Silkworm  Gut 328 

Silver  Wire 331 

Wire  Cutters 350 

Wire  Needles 344 

Wire  Scissors 350 

Sink  for  Operating  Room 101 

Sinusoidal  Current 260 

Skin,  Ascertaining  Sensitiveness  of. ...     68 


INDEX. 


1021 


Page. 

Skin  Grafting 896 

Sleeves,  Rubber 135 

Slides,  Microscopical 33 

Slop  Bucket 93 

Snares,  Cautery 263 

Ear 782 

Nasal 732 

Uvula 654 

Soap  Boxes 139 

Surgical 139 

Sounds,  Calculus 533 

Colonic 882 

Esophageal 699 

Meatus 582 

Medicating,   Urethral 596 

Rectal 876 

Renal 529 

Stomach 710 

Tunneled 585 

Urethral 582 

Uterine 449 

Spatulas,  Eye 812 

Nasal 748 

Spectator's  Coat 134 

Spectroscope 45 

Specula,  Ear 762 

Eye 803 

Rectal  876 

Urethral,  Female 465 

Urethral,  Male 576 

Vaginal 439 

Speculum,  Cervical 513 

Sphygmographs 64 

Sphygmometers 65 

Spinal  Curvature,  Lateral 971 

Lordosis 971 

Pott's  Disease 947 

Spirometer 47 

Spit  Cups 93 

Splint  Material 916 

Splints 916 

Bone  Approximation 926 

Clavicle 928 

Colles'  Fracture 931 

Elbow 930 

Femur 934 

Forearm 931 

Hip- Joint 934 

Humerus 929 

Inferior  Maxilliary 928 

Knee 936 

Leg 936 


Page. 

Splints,  Metacarpal 931 

Patella 932 

Phalanges 932 

Plaster  of  Paris 920 

Septum 756 

Silicate  of  Soda 922 

Starch 922 

Ununited  Fracture 937 

Wire  Gauze 917 

Wood 916 

Sponge-Holding  Forceps 420 

Sponge  Holders,  General 188,  310,  420 

Holders,  Rectal 884 

Sponges 308 

Abdominal 419 

Artificial 309 

Sterilization  of 176 

Spongiopiline  359 

Spools  for  Ligatures  and  Sutures 325 

Spoon  Saw 490 

Spoons,  Ear 768,  787 

Spouts,  Ear 767 

Spray  Tubes 636 

Sprays 630 

Steam 646 

Spuds,  Eye 832 

Nasal 747 

Staff,  Epiglottis 630 

Lithotomy 564 

Urethrotomy,  External 594 

Stands,  Bedside 90 

Suture 114 

Staphyloma 817 

Staphylorrhaphy 694 

Static  Electricity 265 

Stem,  Cervical 506 

Sterilization 138 

Application  of 168 

Boiling 161 

Catgut 171 

Chemical 142 

Dry  Heat 150 

Flame  Contact 150 

Hot  Air 150 

Kangaroo  Tendon 175 

Mechanical 138 

Silk 175 

Sponges  176 

Steam 152 

Sutures  and  Ligatures 171 

Thermal 150 

Water  . .  .162 


1022 


INDEX. 


Page. 

Sterilizer,  Catheter 538 

for  Mouths  of  Bottles 130 

Formaldehyde 146 

Stethometers 45 

Stethoscopes,  Compound 55 

Double 51 

Percussion 58 

Single 50 

Stomach,  Examinations  of 705 

Surgery  of 705 

Tubes 705 

Stools,  Operating 109 

Operators' 610 

Strabismus  by  Advancement 823 

By  Tenotomy 821 

Stretchers 86 

Military 912 

Stricture,  Laryngeal 676 

Urethral,  Treatment  of 579 

Studying  Condition  of  Pulse 63 

Styles,  Lachrymal 837 

Sulphur  Candles 145 

Supporter,  Prolapsus  Ani 893 

Umbilical 902 

Supports,  Nasal 757 

For  Trunk 112 

Surgery,  Bone  and  Joint 367 

Gunshot  Wound 402 

Gynecological 436 

Minor  Operative 270 

Mouth  and  Throat 610 

Obstetrical 854 

Ophthalmic .  800 

Surgical  Pads in 

Pump 203 

Suspension  Apparatus 935,  956 

Suspensories 605 

Suture  Stands 1 14 

Sutures 317 

Suturing 331 

Swabs,  Test  Tube    73 

Urethral 577 

Uterine 455 

Switch  Boards 244 

Symphyseotomy 862 

Syrioges,  Antitoxine 199 

Antrum 760 

Bladder 552 

Cocaine 570,  731 

Drainage  Tube 428 

Ear 766 

Fountain 311 


Page. 

Syringes,  Hemorrhoidal 888 

Hydrocele 609 

Hypodermic 190 

Lachrymal 838 

Mucus 456 

Nasal 728 

Urethral , . . .  597 

Vesical,  Suction 466 

Tables,  Bedside 95 

Dressing 113 

Gynecological 436 

Instrument 114 

Operating 103 

Operating,  Covers  for in 

Tampon,  Nasal 758 

Uterine 506 

Tape  Measures 45 

Tarsorrhaphy 829 

'feeth,  Extraction  of 695 

Tenacula,  General 278 

Abdominal 424 

Uterine 452 

Tenaculum  Forceps 452 

Minor  Operating 305 

Rectal 884 

Tendon,  Kangaroo 320 

Ox 321 

Tenotomes 278 

Tents 461 

Test  Drums 280 

Glasses 78 

Maddox's 846 

Tubes 73 

Tube  Block 471 

Tube  Holders 74 

Tube  Racks 74 

Tube  Swabs 73 

Types 845,  851 

Testes,  Artificial 607 

Thermo-Cautery 219 

Thermometers,  Clinical 57 

Throat  Brushes 650 

Foreign  Bodies,  Removal  of 666 

Mirrors 627 

Tumors,  Removal  of 669 

Thyreoidotomy 685 

Tissue,  Exploration  of 66 

Extractors 67 

Forceps 281 

Forceps,  Abdominal 424 

Tongue  Forceps 186 


INDEX. 


1023 


Page. 

Tonsils,  Ecrasement  of 657 

Hemustats 664 

Lingual,  Treatment  of 665 

Tonsillotomes 661 

Tonsils,  Faucial,  Injections 656 

Faucial,  Treatment  of 656 

Torticollis 945 

Tourniquets ....  292 

Uterine 496 

Towel  Racks,  Hospital 92 

Tracheloplasty 500 

Trachelorrhaphy 500 

Tracheotomes 685 

Tracheotomy 685 

Dilators 689 

Retractors 689 

Tubes 685 

Trachoma 826 

Trajector 405 

Transformer,  Electric 257 

Transfusion  of  Blood 212 

Transportation  of  Patients 83 

Trays,  Bed 95 

Surgical 127 

Trephines,  Skull 393 

Surgical  Engine 392 

Trial  Sets 849 

Trichiasis 830 

Tripods 78 

Trocars,  Aspirating 206 

Curved 547 

Drainage  Tube 316 

Exploring 67 

H  ypodermic 192 

Ovariotomy 476 

Perineum 548 

Plain 208 

Troughs,  Immersion,  for  Microscopical 

Slides 34 

Trumpets,  Hearing 797 

Truss,  Appendicitis 429 

Cystocele 524 

Trusses,  Hernia 898 

Tubes,  Conversation 796 

Diagnostic 773 

Drainage,  Abdominal 427 

Drainage,  Antrum 759 

Drainage,  Chemise 566 

Drainage,  Decalcified  Bone 313 

Drainage,  Perineal 565 

Drainage,  Soft  Rubber 313 

Drainage,  Supra-Pubic 561 


Page. 

Tubes,  Ignition 326 

Instillation 512 

Intubation 677 

Nasal 748 

Permanent,  Esophageal 704 

Rectal 882 

Sediment 78 

Spray 636 

Stomach 705 

Stomach,  Sprinkling 713 

Test 73 

Tracheotomy 685 

Tubing,  Elastic,  for  Compressed  Air..  635 

Tumor  Harpoons 67 

Tumors,  Nasal,  Removal  of 748 

Tuning  Forks 775 

Turn  Table 36 

Twisters,  Wire 348 

Tympana,  Artificial 799 

Uranoplasty 694 

Ureometers 78 

Ureteral  and  Renal  Examinations 468 

Ureters,  Female,  Dilatation  of 472 

Female,  Exploration  of 472 

Urethra,  Applications  to 594 

Foreign  Bodies,  Removal  of 60 1 

Surgery  of 567 

Urethrometers 579 

Urethrotomes 590 

Urethrotomy,  External 594 

Internal 590 

Urinal,  Bladder,  Exstrophy 549 

Urinals,  Portable,  Female 549 

Portable,  Male 548 

Urinary  Analysis 73 

Urine,  Incontinence  of 548 

Retention  of 534 

Test  Apparatus 79 

Test  Cases 80 

Urinometers 75 

Utero-Tractor 491 

Uvula,  Elongated,  Treatment.of 652 

Uvulatomes 654 

Vaporizers 640 

Varicocele,  Treatment  of 607 

Vectus 868 

Venesection 232 

Vibrator,  Ossicle 792 

Vocal  Apparatus,  Artificial 692 

Volsellum  Forceps. . .  .423,  454,  487,  659,  660 


1024 


INDEX. 


Page. 

Ward  Carriages 115 

Wash  Basin 93 

Washstands,  Hospital 91 

Operating-Room 118 

Water  Coils 228 

Pitcher 93 

Wicking,  Pratt's 358 

Wire  Cutters 350 


Page. 

Wire  Shouldering  Forceps 349 

Silver 331 

Twister 348 

Wood- Wool 359 

Wool,  Absorbent 359 

Worsteds  for  Determining  Color  Sense.   845 

Wrenches  for  Bending  Braces 944 

Wrist,  Contracted 977 


Date  Due 

1   H)7i$-pTl 

M^fg 

to  RICO 

C*"j                            CAT.    NO.    23    233                          PRINTED    IN    U.S.A. 

wo  162 

T865m 
1899 


Truax,  Charles 

Mechanics  of  surgery, 


1  surgery 


WO  162 

T865m 

1899 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


